So much has been written on electronic fetal monitoring (EFM) that it is legitimate to ask if there is anything new to say. This ubiquitous piece of technology has been rigorously evaluated over 20 years by randomized controlled trials (RCTs) and systematic reviews, and more recently has been the subject of an Informed Choice leaflet. Yet it is still probably the most widely used technological aid in delivery suites across the country, despite the conclusion of Thacker et al (1996) that 'the use of routine EFM has no measurable impact on morbidity and mortality'. It is timely to attempt an overview of the debate because the gap between evidence and practice is still significant. There is a plethora of study days, books and now software packages all purporting to improve the clinician's interpretation of EFM to the explicit end of reducing perinatal mortality and morbidity.
[...] Acta Obstet Gynecol Scand 63: 1038 Nelson Dambrosia Ting Grether J (1996) Uncertain value of electronic fetal monitoring in predicting cerebral palsy. New Eng J Med 334: 65960 O'Brien Doyle Rolfe P (1993) Near infrared spectroscopy in fetal monitoring. Br J Hosp Med 4837 Organ Berstein Smith Rowe I (1974) The pre-ejection period of the fetal heart: patterns of change during labor. Am J Obstet Gynecol 120: 4955 Rosenblatt Thomas D (1993) WHO Collaborative Study of Neoplasia and Steroid Contraceptives. [...]
[...] Am J Obstet Gynecol 125(3): 31020 Hillan E (1991) Electronic fetal monitoring more problems than benefits? MIDIRS 24951 Hillan E (1995) Postoperative morbidity following caesarian section. J Adv Nurs 103542 Johnson Johnson Fisher J et al (1991) Fetal monitoring with pulse oximetry. Br J Obstet Gynaecol 98: 3641 Kierse M (1994) Electronic Monitoring: Who Needs a Trojan Horse? Birth 1113 Lidegaard Bottcher Weber T (1992) Description, evaluation and clinical decision making according to various fetal heart rate patterns: inter-observer and regional variability. [...]
[...] Education forums locally organized that are mandatory for all clinicians working in intrapartum care should reduce these inconsistencies, though they may make the errors more consistent as well, in the absence of proven ways to reduce false positives results. INTERVENTION / BENEFIT RATIO If the intervention needed to resolve the dilemma of whether a particular EFM trace is genuine fetal distress or not had few clinical sequelae, then the intervention/benefit ratio would tip in favor of 'it's better to be safe than sorry.' However, when that intervention is a caesarean section, benefit has to outweigh considerable morbidity. The study by Nielsen and Hokegard (1984) showed overall intra-operative complications rates of 11.6 were minor complications and major complications. [...]
[...] The complication rate for emergency caesarean sections, which would include the vast majority of fetal distress indications, was Post-operative complications from emergency caesarean sections were a staggering 65% in the same study. Hillan's (1995) review of post-operative complications of emergency caesarean sections at a university teaching hospital, revealed significant levels of postnatal morbidity which included wound infections, chest infections, intrauterine infections, urinary tract infections, urinary catheterization and postnatal blood transfusion. In fact, only of women had no recorded morbidity in the postnatal period. [...]
[...] The 1994 CESDI Report concluded that nearly 11% of perinatal deaths are related to intrapartum events and the review of cases suggested that 46% of these could be classified as sub optimal care where 'different management would reasonably be expected to have made a difference' (p40). Typically, errors in EFM interpretation were commonly cited. In a Unit of 6000 births, this translates to about six cases per year, three of which may have had elements of sub optimal care. An initial impression from these figures is that the incidence of a labor related cerebral palsy or perinatal death is so low as to raise questions about why EFM, already established as a poor predictor of fetal compromise, is so enthusiastically embraced by obstetricians and midwives. [...]
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