Continuous electronic fetal monitoring: contradictions between practice and research

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

No. 197b-Fetal Health Surveillance: Intrapartum Consensus Guideline

OBJECTIVE

This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide intrapartum care in Canada.

OPTIONS

Consideration has been given to all methods of fetal surveillance currently available in Canada.

OUTCOMES

Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered.

EVIDENCE

A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1).

SPONSOR

This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: LABOUR SUPPORT DURING ACTIVE LABOUR: RECOMMENDATION 2: PROFESSIONAL ONE-TO ONE CARE AND INTRAPARTUM FETAL SURVEILLANCE: RECOMMENDATION 3: INTERMITTENT AUSCULTATION IN LABOUR: RECOMMENDATION 4: ADMISSION FETAL HEART TEST: RECOMMENDATION 5: INTRAPARTUM FETAL SURVEILLANCE FOR WOMEN WITH RISK FACTORS FOR ADVERSE PERINATAL OUTCOME: When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased (III-B). RECOMMENDATION 6: DIGITAL FETAL SCALP STIMULATION: RECOMMENDATION 7: FETAL SCALP BLOOD SAMPLING: RECOMMENDATION 8: UMBILICAL CORD BLOOD GASES: RECOMMENDATION 9: FETAL PULSE OXIMETRY: RECOMMENDATION 10: ST WAVEFORM ANALYSIS: RECOMMENDATION 11: INTRAPARTUM FETAL SCALP LACTATE TESTING.

Fetal Heart Rate Auscultation, 3rd edition

The use of intermittent auscultation (IA) for fetal surveillance during labor decreased with the introduction of electronic fetal monitoring (EFM). The increased use of EFM is associated with an increase in cesarean births. IA is an evidence-based method of fetal surveillance during labor for women with low risk pregnancies and considered one component of comprehensive efforts to reduce the primary cesarean rate and promote vaginal birth. Many clinicians are not familiar with IA practice. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues, and strategies to promote implementation of IA into practice.

An Exploration of the Views and Experiences of Midwives Using Intermittent Auscultation of the Fetal Heart in Labor

OBJECTIVES: To identify the experiences of midwives using intermittent auscultation of the fetal heart rate in labor.

DESIGN: A qualitative descriptive study with a sample of 8 midwives, 3 from a DOMINO scheme and 5 from the labor ward at an Irish urban maternity unit. Data collection was through tape-recorded semistructured interviews. Data analysis involved transcription of the interviews verbatim and thematic analysis.

FINDINGS: Three core themes were identified: vulnerability, the culture of the organization, and walking the tightrope. The findings suggest that the main challenges which inhibit midwives using intermittent auscultation is the lack of professional guidelines, inconsistency in documentation, and working in a biomedical model of care. The participants also identified that midwives practicing in a midwifery social model of care have more confidence and use midwifery skills to support the use of intermittent auscultation.

CONCLUSIONS: The findings suggest working within a midwifery social model of care facilitates the use of intermittent auscultation. Guidelines and education on the explicit use of intermittent auscultation need to be made accessible to midwives. Midwives believed that women could promote the use of intermittent auscultation through their own education on monitoring fetal heart rate options in labor.

Midwives' and doctors' attitudes towards the use of the cardiotocograph machine

The appropriate use of the cardiotocograph (CTG) machine in the clinical setting is an issue of concern for midwives and doctors.

OBJECTIVE

To examine midwives and doctors attitudes towards the use of the CTG machine in labour ward practice.

BACKGROUND

this small study provides new insight into the attitudes of doctor and midwives towards the use of CTG.

DESIGN

An exploratory descriptive design that used a combination of qualitative and quantitative approaches. A valid and reliable tool designed by Sinclair (2001) was used to measure the attitudes of doctors and midwives towards CTG usage. In addition, follow-up semi-structured interviews with doctors and midwives were conducted.

SETTING

A maternity unit in Northern Ireland.

PARTICIPANTS

Participants selected had worked in the labour ward within the last year (n = 56 midwives; n = 19 doctors). Six midwives and two doctors were randomly selected to participate in the interviews.

FINDINGS

The study demonstrated a favourable disposition towards the use of CTG machines with 72.5% (n = 29) of respondents indicating that they viewed CTG technology positively and 87.5% (n = 25) indicating they were confident about their skill in interpreting CTG tracings. The majority of the respondents (60.0%, n = 24) felt that their training adequately prepared them for using CTGs. The illustrative accounts provided by the respondents demonstrated a predominant belief that CTG technology continues to have a role in monitoring and detecting abnormalities in the fetal heart rate but this role is limited by how well the CTG is used and interpreted. The interviews confirmed the data obtained from the questionnaires and revealed a number of professional needs and concerns relating to CTG usage.

IMPLICATIONS FOR PRACTICE

The implication of this study may be focused on addressing the training needs of students, newly qualified staff and regular updates for employed staff. There was some concern that this technology may be deskilling staff and therefore there is a need to improve confidence levels in using alternatives to this type of fetal monitoring.

Foetal monitoring: a woman-centred decision-making pathway

PROBLEM

Many midwives continue to use continuous foetal monitoring on low risk women in labour, despite evidence based clinical guidelines to the contrary. Continuous foetal monitoring has been linked to increased rates of medical intervention during labour and birth with no improvement in long term neonatal outcomes.

PARTICIPANTS

Midwives who used continuous foetal monitoring on low risk women in labour at two regional Queensland hospitals.

METHODS

This Grounded Theory study explored midwives' decision-making processes related to the use of continuous electronic foetal monitoring on low risk labouring women. Primary data were gathered in semi-structured interviews with five purposively selected midwives and concurrently analysed using Grounded Theory techniques of theoretical sampling and constant comparison.

FINDINGS

The midwives made the decision that led to continuous electronic foetal monitoring on low risk women at two key decision points during labour care; the first during the midwives' initial assessment of the woman and foetus, and the second when the midwives categorised the women as high or low risk. However, various factors impacted on these decisions including trust and staff workloads within a context of risk management and medical dominance. There was limited opportunity for women to be involved in the decision-making process about foetal monitoring and only partial information was provided prior to cardiotocography.

CONCLUSIONS

Consistent with current clinical guidelines which recommend open, consultative discussion with the woman about foetal monitoring and a partnership approach towards decision-making following informed choice, a woman-centred foetal monitoring decision-making pathway is proposed. This pathway is applicable in midwifery education, research and clinical practice to promote both evidence based practice and woman-centred decision-making.

Central fetal monitoring: effect on perinatal outcomes and cesarean section rate

BACKGROUND

In a trend similar to continuous electronic fetal monitoring, many hospitals are incorporating central fetal monitoring into labor and delivery suites. The objective of this study was to investigate whether the use of central fetal monitoring had an effect on neonatal outcomes or cesarean section rate.

METHODS

This retrospective study involved patient data from deliveries occurring at Women and Children's Hospital of Buffalo, Buffalo, New York, between the years 2000 and 2003. In the period from January 1, 2000, to December 31, 2001, central fetal monitoring was available, whereas in the period from February 1, 2002, to December 31, 2003, it was unavailable. Data on deliveries at Women and Children's Hospital of Buffalo were obtained using the Western New York Perinatal Data System, which is an electronic data set based on birth certificate information. The method of delivery, admission to the neonatal intensive care unit, and 5-minute Apgar scores less than 7 were compared for deliveries occurring with and without the use of central fetal monitoring. These outcomes were further subdivided into full-term and preterm deliveries.

RESULTS

Three thousand five hundred and twelve deliveries used central monitoring and 3,007 deliveries did not. For full-term deliveries, in the years with central fetal monitoring compared with the years without it, no differences in the cesarean section rate (13.4 vs 14.5%, not significant [NS]), the admission rate in neonatal intensive care unit (3.3 vs 3.3%, NS), or the incidence of Apgar score less than 7 (0.6 vs 0.5%, NS) were observed. For preterm deliveries, comparing the years with central fetal monitoring with the years without, no differences in the cesarean section rate (21.3 vs 21.3%, NS), the admission rate in neonatal intensive care unit (17.7 vs 20.1%, NS), or the incidence of Apgar score less than 7 (7.0 vs 6.5%, NS) were observed. Analyses pooling all deliveries also failed to show any differences in any of the parameters.

CONCLUSIONS

No statistically significant difference was demonstrated in the rates of cesarean section, admission to the neonatal intensive care unit, or incidence of Apgar scores of less than 7 associated with the use of central fetal monitoring. Therefore, we could not identify any benefit to the use of central fetal heart rate monitoring.

The rhetoric of informed choice: perspectives from midwives on intrapartum fetal heart rate monitoring

OBJECTIVE

To investigate midwives' attitudes, values and beliefs on the use of intrapartum fetal monitoring.

DESIGN

Qualitative, semi-structured interviews.

SUBJECTS AND SETTING

Fifty-eight registered midwives in two hospitals in the North of England.

RESULTS

In this paper two main themes are discussed, these are: informed choice, and the power of the midwife. Midwives favoured the application of informed choice and shared a unanimous consensus on the definition. However, the idealistic perception of informed choice, which included contemporary notions of empowerment and autonomy for women expressing an informed choice, was not reportedly translated into practice. Midwives had to implement informed choice on intrapartum fetal monitoring within a competing set of health service agendas, i.e. medically driven protocols and a political climate of actively managed childbearing. This resulted in the manipulation of information during the midwives' interactions with women. This ultimately meant that the women often got the choice the midwives wanted them to have.

CONCLUSIONS

The information that a midwife imparts may consciously or subconsciously affect the woman's uptake and understanding of information. Therefore, the midwife has a powerful role to play in balancing the benefits and risk ratios applicable to fetal heart rate monitoring. However, a deeply ingrained pre-occupation with technological methods of intrapartum fetal monitoring over many years has made it difficult for midwives to offer alternative forms of monitoring. This has placed limits on the facilitation of informed choice and autonomous decision making for women.

Medicaid Coverage and Medical Interventions During Pregnancy

This paper extends prior research on the effect of Medicaid coverage on medical interventions during pregnancy (prenatal ultrasound) and birth (ultrasound during delivery, cesarean delivery, inducement, and fetal monitor). The data are from two sources: the New York State Vital Statistics (VS) matched infant birth-death file and the Statewide Planning and Research Cooperative System (SPARCS) file for 1993--1996. Medicaid coverage increases the likelihood of teens and adults receiving prenatal care relative to being uninsured. Overall, the effect of insurance type varies depending on whether the procedure is part of standard care (ultrasound and fetal monitor) or more likely to be elective (inducement and cesarean delivery). Insurance type has a greater effect for elective procedures than for procedures that are part of standard care.

Should women be given a choice about fetal assessment in labor?

Continuous electronic fetal monitoring (EFM) in labor is one of the most commonly used interventions during intrapartum care. However, randomized controlled trials, observational studies, and meta-analyses about the use of continuous EFM on low-risk intrapartum patients have found no significant differences in infant outcomes between infants whose mothers had EFM or intermittent auscultation (IA) of the fetal heart rate. In addition, research shows a higher incidence of cesarean birth when EFM is used. Although evidence-based practice is supposed to be our goal, the evidence about the lack of efficacy of EFM has not been used in practice. In fact, EFM has become the standard of practice in this country. Considering these facts, should EFM continue to be the standard of practice for low-risk laboring women? Is informed consent indicated, giving women the choice between EFM and IA? Should IA be offered to all low-risk laboring women? Ethical decision-making models are used to examine those questions and to help nurses better delineate their advocacy role.

A New Understanding of the Second Stage of Labor: Implications for Nursing Care

A reconceptualization of the second stage of labor is proposed, with an early phase of descent and a later phase of active pushing, as the basis for nursing care related to direction or support of expectant mother's bearing-down efforts. This reconceptualization challenges the rules that have accompanied second stage by providing criteria for the obstetric conditions optimal for fetal descent that develop during the initial phase of second stage as the fetal head rotates to an anterior position and descends to at least a 1+ station. The phase of active pushing is accompanied by a decline in fetal pH and should be shortened, not only by assisting the woman with effective bearing-down but also by allowing a longer early phase of second stage and encouraging the woman to push only when the obstetric conditions are optimal.

Technology in the birthing room

The use of technology is not benign. As with any health care intervention, there are associated risks and benefits. The practitioner needs to constantly consider the benefits of the technology versus the naturalistic birth experience. The use of technology should optimize birth outcomes while maintaining a balance that provides for the best possible human birth experience. Technology, however, does have merit in the birth setting, regardless of location, but its use should be evaluated on an individual, as needed, basis. The most common technological advances currently available for assessment and maternal/fetal care during birth include electronic fetal monitoring, ultrasonography, blood pressure screening, maternal/fetal pulse oximetry, and infusion pumps. All obstetrical care providers must be familiar with the forms of technology currently available and be aware of emerging technologies for use during the birthing process.

Intrapartum fetal monitoring: past, present, and future

The concept of intrapartum "monitoring" of the fetal heart rate by auscultation has been extant for almost 200 years and by electronic means for more than 30 years. This article explores historical aspects of fetal monitoring, the advent of electronic fetal monitoring and its controversies, and present and future research opportunities to enhance the reliability, validity, and efficacy of fetal monitoring.

Fetal heart rate monitoring: interpretation and collaborative management

Effective intrapartum fetal heart rate (FHR) monitoring requires ongoing collaboration among health care providers. Nurses, midwives, and physicians must have a shared understanding of 1) how FHR tracings are interpreted, 2) which FHR patterns are associated with actual or impending fetal acidemia, 3) when and within what time frame the physician or the midwife should be notified of variant FHR patterns, 4) how quickly physicians and midwives should respond when notified of variant patterns, and 5) the indications for and optimal timing of interventions such as operative delivery. This article reviews the literature on FHR monitoring and includes a discussion of the advantages and limitations of different monitoring modalities. An overview of those FHR patterns are associated with presumed fetal acidemia is presented, as well as sample multidisciplinary FHR monitoring guidelines and an exercise in intrapartum FHR pattern evaluation that can be used to initiate development of local FHR monitoring patterns.

Legal implications of fetal heart assessment

The standard of care requires perinatal nurses to perform fetal heart (FH) assessment competently and safely. Failure to adhere to established guidelines and standards for FH assessment may result in negative outcomes for the fetus or newborn and contributes to claims of nursing negligence. The perinatal nurse must be fully cognizant of professional guidelines and standards for FH assessment and comply with agency policies and procedures when conducting assessment of the fetal heart. Guidelines for FH assessment during the antepartum and intrapartum period are discussed within the context of restructured health care settings and today's medicolegal climate.

Computer analysis of the fetal heart rate

Computer analysis of the fetal heart rate is a technology of the Information Age commercially available for research and clinical practice. Intelligent systems are engineered with algorithms or neural networks designed to simulate expert knowledge. Automated analysis has provided objective, standardized, and reproducible data used to research fetal heart rate responses in the antepartum and intrapartum setting. Perinatal information systems can integrate FHR analysis and data management.

History and development of fetal heart assessment: a composite

Methods of assessing the fetal heart remained unchanged for approximately 150 years until the first commercial monitor suitable for clinical practice was sold in 1968. The impact and events of the last 30 to 40 years surrounding fetal heart assessment are revealed in perspectives of the past, present, and near future. Assessment practices have been shaped by the development of biotechnology, unrealistic expectations, interpretation disagreement, consumer response, and the practice and educational resources written by nursing and medicine.

Fetal heart rate auscultation: current and future practice

Intermittent auscultation (IA) has been reported as equivalent to electronic fetal monitoring (EFM) as a fetal surveillance method in terms of neonatal outcomes based on randomized controlled trials and meta-analyses. Despite recommendations to include IA as a primary method for fetal evaluation, EFM use predominates. Understanding the equipment, method, benefits and limitations, and strategies for implementing IA may assist nurses in providing informed choices for low-risk pregnant women.

Intrapartum fetal surveillance

Intrapartum hypoxia was thought to contribute to the incidence of cerebral palsy, seizures and mental retardation. Electronic fetal monitoring was expected to prevent or reduce this incidence. Electronic fetal monitoring has a high false positive rate and fetal blood sampling, which is an invasive procedure, only allows an intermittent assessment. Efforts are being made to improve fetal heart rate analysis and clinical management. Fetal pulse oximetry, fetal electrocardiogram waveform analysis and the intermittent measurement of lactate levels by fetal blood sampling may become established as an adjunct to electronic fetal monitoring.