As we mentioned, there are a variety of devices that can be used for hands-on listening during labor. Cochrane researchers conducted a review and meta-analysis to find out which types of listening tools and timing protocols are most effective Martis et al. They were only able to find two randomized, controlled trials to contribute data to the meta-analysis. The studies were conducted in Zimbabwe and Uganda and included a total of 3, participants.
When the two studies were combined, they found that a handheld Doppler battery and wind-up is linked to more Cesareans for abnormal fetal heart rate compared to a Pinard fetal stethoscope, but without a clear difference in newborn health outcomes low Apgar scores, newborn seizures, or perinatal death. However, the quality of the evidence is low and other important newborn health outcomes were not assessed.
There is not enough evidence at this time to recommend a Doppler ultrasound or a type of fetal stethoscope as the preferred listening device. Researchers have looked into the evidence for this practice. They found four studies from the U. Altogether, the studies included more than 13, low-risk participants.
The researchers found a tendency towards more Cesareans among the people randomly assigned to EFM on admission compared to those assigned to hands-on listening on admission, but the finding was not statistically significant. This means that more data is needed before we can detect if there is a real impact of admission EFM on Cesareans.
People assigned to EFM on admission were more likely to end up being put on continuous EFM for the rest of their labor. There were no differences in newborn health outcomes between the groups, including newborn seizures. The authors concluded that there is no evidence of benefit for using EFM on admission in labor among low-risk women, and that hands-on listening is the preferred method. Electronic fetal monitoring usually requires that a mother wear two monitoring belts around her abdomen during labor, which restricts movement and may even require bed rest.
Electronic fetal monitoring also usually means that the mother loses the option of water immersion in a birth pool for pain management. Not all types of continuous EFM restrict mothers from movement. Mobile monitors are designed to free up mothers, but they are not perfect. Because they are a continuous monitor, they may carry the same increased risk of Cesarean. Another potential downside of EFM is that the sounds or display from the monitor could distract laboring people, leading to an increase in their perceived pain during labor.
They found that for some people, watching the monitor made them feel more distracted and stressed, which was linked to feeling more pain during labor. Laboring people may also feel less supported by their care providers if the providers pay more attention to the monitor than to the person wearing the monitor.
Researchers have found that women who do not feel supported by their care providers report more pain and less satisfaction with childbirth Hodnett Perhaps the most important risk of electronic fetal monitors to be aware of is their effect on Cesareans. In the U. Because non-reassuring fetal heart tones can be a vague diagnosis, several professional organizations in the U. It may be possible to reduce preventable Cesareans from EFM by using scalp stimulation and attempting corrective measures to resolve the concerning fetal heart rate.
However, continuous electronic fetal monitoring generally restricts people to bed-lying positions. Having the mother change positions may be helpful for relieving umbilical cord compression that can cause abnormal fetal heart rate patterns.
One of the main reasons EFM is so common is that doctors, nurses, midwives, and hospitals think that it protects them from cerebral palsy lawsuits. However, the introduction of EFM actually had the effect of increasing rates of medical malpractice lawsuits Spector-Bagdady et al.
However, the technology was used against them in court, and trial lawyers for parents were able to win billions in lawsuits against physicians Sartwelle et al. One big reason that EFM dominates labor and delivery units today is that judges and juries decide on whether or not a provider committed medical malpractice based upon something called the standard of care.
Standard of care means, how did this doctor practice compared to how other doctors are currently practicing? Standard of care does not mean best practice, and it also does not necessarily mean evidence-based practice. This catches doctors, nurses, and midwives in a catch the use of EFM is not best practice for many women. The lack of an EFM recording increases the chance that the hospital will lose the lawsuit or have to settle the lawsuit, losing a large amount of money either way Spector-Bagdady et al.
Many hospital labor and delivery units may own only one or two handheld Dopplers—or none at all. Hospital administrators may not understand the value of purchasing small devices for hands-on listening when they have already spent a large amount of money equipping their units with high-tech electronic fetal monitors. With hands-on listening, the nurse, midwife, or doctor actually has to be at the bedside of the laboring person every minutes during the active phase of the first stage of labor and every minutes during the pushing phase of the second stage of labor.
One unexpected benefit of hands-on listening is that it requires caregivers to spend more time with the laboring mother—and their more frequent physical presence may actually lower pain and increase satisfaction for their patients Hodnett Electronic fetal monitoring is big business.
In the early s, there were approximately 28, fetal monitors in more than 3, hospitals in the U. Hospitals spend significantly more on electronic monitoring systems compared to handheld Dopplers. However, on the other hand, EFM may actually require more time than they realize Smith et al.
For example, the time taken to maintain EFM equipment, adjust the monitoring belts, continuously watch the monitor, respond to alarms, and interpret the fetal heart strip, could take longer than the time required to use hands-on listening for minutes every minutes during active labor. In addition, if EFM causes increased maternal discomfort leading to an increased need for pain medication, then this will require increased observation by clinical staff and ultimately a greater strain on human resources.
In the end, using electronic fetal monitoring for everyone is an example of high-tech, high-cost, non-evidence-based care. Most nurses and doctors are not familiar with using a fetal stethoscope and many have little or no training in hands-on listening. I have seen one [fetal stethoscope] in Africa. Hospitals often choose to offer the course as continuing education for their staff from regular course offerings across the U.
Some hospitals even require their labor and delivery nurses to get this certification. Overall, most nurses and physicians are much more comfortable using EFM rather than hands-on listening, since they have had more training and experience with EFM.
Also, if a hospital has not trained their nurses in hands-on listening, or does not have a written policy or protocol, it might be impossible for their nurses to provide this service.
Researchers in Ontario, Canada recently interviewed 12 birthing unit nurses about their views on fetal monitoring during labor Patey et al. The nurses in these Canadian hospitals reported that they were very comfortable and confident in their ability to use hands-on listening, but that competing tasks, time limits and the need to multitask get in the way of being able to use hands-on listening with laboring mothers.
They also reported that hospital legal concerns were sometimes prioritized over the benefits of hands-on listening. Some nurses reported that hospital policies and a lack of support from care teams limit their use of hands-on listening.
Missing and broken handheld Dopplers were also mentioned as a barrier. The review included 11 studies with a total of 1, participants. However, over time, fewer professionals reported that EFM leads to a good newborn health outcome. The growing evidence that EFM carries risks without clear benefits has probably influenced their views.
The authors point out that advances in technology include the ability of a handheld Doppler to store information. The research overwhelmingly supports hands-on listening compared to EFM, and practice guidelines should state this clearly. There has been recent progress, as we will discuss below; however, all evidence-based practice guidelines should recommend hands-on listening as the preferred method of fetal monitoring.
ACOG states that hands-on listening may not be appropriate for people at increased risk of complications such as those with meconium staining, bleeding during labor, suspected fetal growth restriction, preeclampsia, prior Cesarean, type 1 diabetes, or receiving Pitocin.
The clinical bulletin of the American College of Nurse Midwives ACNM states that hands-on listening—not electronic fetal monitoring—should be the preferred method of fetal monitoring in people at low risk for complications ACNM The Society of Obstetricians and Gynecologists of Canada state that there is no evidence to justify the use of continuous EFM in routine practice, and that hands-on listening is the preferred method of fetal monitoring for low-risk women i.
Instead, the guidelines suggest that low-risk laboring people be offered hands-on listening with either a Pinard fetal stethoscope or a Doppler ultrasound. Continuous EFM is recommended if the fetal heartbeat remains abnormal, but the mother should be offered hands-on listening again after 20 consecutive minutes of normal EFM readings. Different guidelines list different reasons why certain people should not have hands-on listening, and instead have EFM.
However, these contraindications are based on clinical opinion, since there is no supporting evidence from studies that have compared EFM with hands-on listening in these specific groups. Most guidelines recommend continuous EFM for people in labor who have had a prior Cesarean. This is because the most common sign of uterine rupture is fetal heart rate abnormality. We only found one study that compared continuous EFM versus hands-on listening in people with a history of Cesarean, but unfortunately this study was too small mothers to offer any useful evidence about EFM vs.
You would need about 12, people in each group in order to find a difference in the rate of uterine rupture between groups Bujold et al. Grab our one-page handout on Fetal Monitoring to take to your next appointment! The bottom line Electronic fetal monitoring EFM was brought into labor rooms in the s, despite the fact that there was no research evidence to show that it was safe or effective. Randomized trials have found that EFM has contributed to an increase in the Cesarean rate, without making any improvements in cerebral palsy, Apgar scores, cord blood gases, admission to the neonatal intensive care unit, low-oxygen brain damage, or perinatal death which includes stillbirth and newborn death.
EFM is linked to a lower rate of newborn seizures; however, newborn seizure events are rare and it is not clear how often they lead to long-term health problems. Electronic fetal monitoring is a tool, and care providers can learn to be better stewards of this technology. Efforts are underway to prevent Cesareans by defining abnormal heart patterns with standard definitions. Category II tracings, in particular, should be addressed first with preventive measures and scalp stimulation before deciding to perform a Cesarean.
Some hospitals now offer wireless, water resistant continuous electronic monitors. Mobile monitors may offer mothers more mobility during labor and the option of showers to cope with labor. To make a fully informed choice, laboring people need to understand the potential risks and benefits of the different approaches to fetal monitoring.
Evidence supports hands-on listening—a low-tech, high-touch approach—for people giving birth without known complications. Practice guidelines encourage the use of hands-on listening with low-risk people. However, hands-on listening is still not easily available in most hospitals. In many birth settings, low-risk people are still told that EFM either continuous or intermittent is required during labor.
The reality is that there are system pressures in hospitals that limit doctors, midwives, and nurses from truly supporting birthing people. If hospitals were willing to invest in more hands-on care to support women during childbirth, we would likely see more hands-on listening. Understandably, clinicians also want to protect themselves from expensive lawsuits.
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The authors received no financial support for the research, authorship or publication of this article. The data and materials supporting this article are publicly available and included in the endnotes. You can also search for this author in PubMed Google Scholar. All authors contributed to the research, drafting, reviewing and editing of this paper. All authors read and approved the final manuscript.
This damning report emerged at a time when true electronic fetal monitoring EFM was being developed and experts were quick to dismiss IA in favor of the hoped-for promise of EFM. In Cremer described the use of the fetal electrocardiogram using abdominal and intravaginal electrical leads. That led other investigators to attempt to determine fetal status using electrocardiographic patterns only to conclude that fetal distress did not yield any consistent electrocardiographic patterns.
Electronic fetal phonocardiography had been described originally by Henly in These devices simply used a microphone to magnify the auscultated FHR. In , Callagan described a commercially viable system for capturing the FHR with Doppler technology. In the s, EFM systems were made commercially available by Hon in the United States ; by Hammacher, a pioneer in the electronic systems to reduced noise-to-signal ratios, in Germany; and in Uruguay by Caldeyro-Barcia, father of among other things, Montevideo units and long-term and short-term variability.
Hon had coined the terms early, late, and variable decelerations. The spiral electrode or fetal scalp electrode as used today was introduced by Hon in
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