Monday, October 3, 2011

Electronic Fetal Monitoring -- Is it really saving babies?

 As Tim McGraw's biggest fan, I subscribe to a number of Country news emails and Facebook groups.  I skip over most of it, but sometimes I'll see something that catches my eye that is not even related to Tim.  As you can imagine, it usually has to do with someone having a baby.

A couple of weeks ago it came across my News Feed that Jewel was showing off her new baby.  She lives in this area of Texas, about an hour from me, and because we have about a 50% c-section rate, I was very curious how things turned out for her.  (I had heard that she had desired a "natural birth.") 

The story goes that she was doing Hypnobirthing -- no details available.  Could have been self-study or CDs, maybe a class.  So I assume that desiring a "natural birth" really did mean an unmedicated birth, not just a vaginal birth.

The article went on to describe how violent the Braxton-Hicks contractions were and put the baby at risk.  Yadda, yadda, yadda... she had an emergency c-section that miraculously saved her baby.

The singer, who studies hypnobirthing, was eager to have a natural birth, but things didn’t work out as planned. When Jewel started having early Braxton Hicks contractions, Kase’s heart rate dropped. She admits, “I feel lucky to be pregnant in the modern age where they could actually tell he wasn’t well during those contractions.”  

In the end, Jewel says her scheduled birth plan wasn’t what was important to the young family. “We felt thankful that we had good doctors and a good hospital nearby, and that everything was OK,” she says. “I’m so lucky that we have a healthy baby boy. That’s all I cared about.”

I can't help but think this poor reporter got his terms mixed up about the contractions, and there's little information to go on from there.

Regardless, how many women have had c-sections that truly believe they were necessary -- that their baby would have died without the surgery?  Countless.  The year the Electronic Fetal Monitor was introduced, we went from a 5% c-section rate to 23%.  Studies have shown time and again that a baby who is truly in distress will be picked up with intermittent monitoring.  (Side note:  "intermittent" means different things to different care providers.  It may mean during and between a couple of contractions per hour, or 20 minutes per hour.  Find out what intermittent means at your place of birth.)

One of the problems with the continuous monitoring is the lack of communication between the birth team and the parents.  Mom is monitored from down the hall, and when a nurse does walk in, she tends to look at the monitor and not the laboring woman.  Another problem is obvious:  mom can't move around and help her baby out.  The baby is left to figure it out on his/her own. 

Problem number 3:  Any time a mom receives drugs of any kind, she'll be put on a monitor to be sure the baby is handling it OK.  This can mean hours and hours of a baby being exposed to ultrasound.  That's what Electronic Fetal Monitoring is -- ultrasound.  I've written posts on the risks of ultrasound in the past.  Click here and here and here.  You need to decide how comfortable you are with this intervention.

Problem number 4:  The biggest problem of all is simply that they have to do something with the results of the readout.  Take a baby that has a cord around the neck, for example.  This baby will have decels of the heart rate on the printout.  They aren't sure why the baby's heart rate is dropping, but better safe than sorry, right?  Lawsuit alarms start going off and a c-section is performed.  The baby is fine (Jewel's baby looked great!), but there is this perception -- or defense mechanism -- that thank goodness the c-section was performed and saved the baby. 

Was the baby ever in trouble?

We'll never know.  But now, because it's so hard to find a VBAC-friendly doctor, we've put this mom on a c-section path for all her children -- unless of course she becomes informed of her VBAC options.  As an OB, this is exactly where I want her.  Easier for me and twice as much money.  Few women will question the c-section because it makes her look like a bad mom.  She trusts her doctor.   It's easier to believe that the surgery saved the baby.

Another side note:  The cord around the baby's neck occurs in about one in three births.  When a c-section is performed where the cord is around the neck, the OB often makes a big deal about it, making the parents feel like this was very dangerous.  It's not.  The OB or midwife, after the head is out, will simply lift it over the baby's head.  It could be wrapped around the neck several times!  The most I've seen from one of my student's was 4 times!  Had she stayed with her original hospital and OB -- who required continuous monitoring -- she assuredly would have had a c-section.  Instead, she had a fabulous water birth with CNMs at a different hospital.

So, I feel bad for Jewel.  Maybe her baby really was in distress, but I suspect that the doctor didn't want such a public birth taking a chance at going sour.  Given the high c-section rate in our area, perhaps he was less comfortable with (unmedicated) vaginal birth than cesarean birth.  He knew he could perform a mean c-section and spin it like he saved the baby.  Again, just me speculating.  I do believe that she was likely another victim of our broken maternity system and doesn't even realize it.  While I always advocate for women being informed of their choices in childbirth, sometimes ignorance is probably quite blissful.


Janie said...

It might be wrong but it reminds me of sentiments when a woman is taken advantage of by a womanizer..
"but he told me he loved me"
"he said he was leaving her"
"he said I was the only one"
and you think... he says that to all the girls..."
When women with csections say
"they said my baby would die"
"they said I couldn't complete labor"
"they said my hips were too small"
I think...
they say that to all the girls...

celebrities do seem to have it bad - they are almost all csections these days if they are not planned homebirths.

** Not that I think all csections are not needed - Just about less than a quarter of all the ones I hear about seem truly warranted.

Mama E said...

I'm a patient of Dr. Cummings and he put it best at an ICAN meeting:

"You're baby's heart rate may drop during a contraction, but that's not necessarily a sign of distress. Imagine if I got on top of you and pushed down as hard as I could on your head. Don't you think your heart rate would drop as well?"

And it's celebrities who are misinformed like that who contribute to our rising c-section rate. They make it seem "cool."

mom of 6 miracles said...

I HAD to have a c-section with my 3rd child due to placenta abruption, the baby and I almost died due to I wasn't bleeding out since my bag of water blocked the way like a suction cup. I was passing out and babys heart rate dropped drastically. In the instance it was 100percent the correct thing that was needed. With my 4th child I was turned away from 3 different hospitals that refused to give me a v-bac. I kept searching knowing I should be able to have a natural birth... Finally found a doctor and a hospital and have had 2 kids since naturally with no intervention. Our bodies know what to do.. It is us who lack faith in the beautiful process of birthing and put too much trust into the doctors than what God truly meant for our bodies. I was higher risk than most too since I have preterm labor issues and an incompetent cervix too. I my first 3 kids were early.... My 4th and 5th full term!!! I am now pregnant for my 6th and trust my body to tell me when something is wrong. I always refuse all the pre screening tests ( since they are not accurate and only make us worry more). On top of it all... My husband and I are carriers of CF. We have two beautiful little girls with the disease, but are in good health currently. We also had a son that passed away ( second child) due to being born with no kidneys 1 in 10,000 chance for anyone which we are not even carriers for. We found out at five months and were told he wouldn't live after birth and most likely would die before birth and were urged to abort. Needless to say we carried him until his time and met our son ALIVE and got several wonderful hours with him before he went on the be with our savior. If we listened to the doctors , we would have never gotten that time and I wouldn't change it for the world. things happen that are sometimes out of our control, but we have to put our trust where it rightfully belongs... In theLord!

Sarah--Well Rounded Birth Prep said...

Yes, and this is echoed by the fact that so many "fetal distress" cesarean babies are born pink and screaming with Apgars of 8 and 9. How distressed were those babies?

Ginger said...

So who is Jewel anyway?
I did a research paper on continuous fetal monitoring & cerebral palsy in grad school. The professor really didn't like that paper, although it was well-researched. Got a C.

Celia Marie (W.) B. said...

I had an "emergency c-section" with my first because of heart rate dropping during contractions. I remember being so drugged up after that c-section that I was shaking too violently to hold my baby, all the while thanking the doctor for saving my baby. I wish so badly I'd taken a class like this before. My doctor had actually said there was no need to take a child birth class because "they'd walk me through it." Ha.

I carried the notion with me that I was too small to birth a baby and had a repeat c-section for my next. I am now preparing for my 3rd birth, VBA2C, unmedicated, with a doula and Dr. Cummings at the end of the table. It's going to be different this time. Even if it ends in a c-section, it's not going to be because I was ignorant, afraid, tricked or bullied into it.

Olivia ♡ said...

@Sarah - just because the baby came out screaming and pink doesn't meant that there wasn't distress. Would you have been happier with a vaginal birth where the baby comes out blue and not breathing? No.

Amy Tuteur, MD said...

"The year the Electronic Fetal Monitor was introduced, we went from a 5% c-section rate to 23%."

That is completely untrue. You simply made it up.

The C-section rate rose from 5% to 23% over a period of 25 YEARS from 1970-1995.

Janie said...

That's what she chose to dispute? good one... even if she is right.. its like we didn't start birthraping women right away we ramped it up slowly over time.

Mama Birth said...

I beg to differ Amy- You are also incorrect. According to the CDC :
The c-section rate in -
1970 - 5.5%
1975- 10.4
1986- 24.1

Unless I am doing my math wrong, that was 16 years (not twenty five) to hit a rate of 24% (and some change). Donna was incorrect, but so were you.

Mama Birth said...

Oh, and you can check the data, here

Amy Tuteur, MD said...

Sorry, but I don't any data that shows that "The year the Electronic Fetal Monitor was introduced, we went from a 5% c-section rate to 23%."

That would be because you made it up.

Amy Tuteur, MD said...

Moreover, you neglected to mention that during the same time period, neonatal mortality dropped by more than 50%.

Mama Birth said...

You can check the data for WHAT I CLEARLY POSTED on the CDC website which I linked to-
Would you care to share your data?

Jessie Roberts said...

Neonatality has dropped mostly in part not because of obstetric practices, but because of advances in perinatal medicine. We haven't gotten better at birthing babies, just saving the ones who are sick.

Amy Tuteur, MD said...

"Neonatal mortality has dropped mostly in part not because of obstetric practices, but because of advances in perinatal medicine."

Do you have any data to support that claim?

Jessie Roberts said...

"But the idea of progress in obstetrics is to a great extent a myth. The maternal mortality rate in the United States is not going down, it is going up, and the slight fall in the rate of babies who die around the time of birth (perinatal mortality) in the past ten years is due not to a decrease in the percentage of babies who die before they are born, but rather to a slight decrease in the rate of babies who die shortly after birth, which can be attributed to neonatal intensive care, not obstetric care. There has been no improvement in the past twenty years in the rate of babies born who are too small-a major cause of neurological handicap-and in 2004 the rate went up. Nor has there been any lowering of the rate of babies who develop cerebral palsy."

Marsden Wagner. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (p. 74). Kindle Edition.

Amy Tuteur, MD said...

I asked for data, not Marsden Wagner's writings for laypeople. Please present some data.

Mama Birth said...

Amy ----I did clearly state and link to proof of my assertion that yo are also wrong- moreover I admitted that the author of this blog was also incorrect in her assertion. I- MAMA BIRTH- did back up MY claim with evidence. Can you please back up yours?

I would love to see your proof that it in fact took 25 years to hit a 24% c-section rate when the CDC evidence says it took 15. You threw out a number that is MADE UP too. Calling yourself a doctor does not change the fact that you also manufactured data. I never did that.
Still waiting for your proof. Could it be that you too sometimes misspeak? Or are you just making stuff up?

Jessie Roberts said...

I'm not going on a wild goose chase all over the internet for you, Amy. I've been round once with you before, I am so not making that mistake again. I have much better things to do with my time than to argue with you.

Marsden Wagner is a perinatologist, and former director of Women & Children's Health at WHO. If his credentials don't give him some credibility, I don't know what does. He's done his research -- more thoroughly and with greater understanding than I ever could. You can choose not to accept it, but it doesn't make it invalid.

Janie said...

LOL, mama birth.. crickets chirping - do we know what started her bent in the first place? is there a back story to her trolling?

My Educated Birth said...

Okay, so I hate to be the gray goose in a pond full of white ones, but I got stuck on one thing in all of the comments - maternal mortality increasing. I began to really ponder that. It's not a hugely significant increase from what I've read in the large scope of things. So perhaps it's things like the fact that more people are getting pregnant that normally couldn't due to infertility treatments, for one example? What about medications that make people who normally may be excluded from society be included? It's fantastic technology and medical work, but it also means that some DNA chains are continuing, progressing, or causing problems. It also could be the increase in our average weight as a nation. I think there are so many factors to consider that it doesn't seem fair to point fingers and blame one thing like OB care.

Of course, I've seen some crap OB's. But there are also crap CNM's and CPM's, too - you have that in every profession.

seili said...

The hard part about this is, you really don't know until it is retrospect whether or not a c-section was definitely needed. And that not knowing can make a big difference for some people; some might like to take the chance, others wouldn't.

FlippyHippy said...

I have changed my position on my reaction to "emergency c-sections" over the past year. I used internally 'roll my eyes' most times when moms told me that their baby "would have died", especially when given reasons like "the baby was too big" or "I was in labor for 2 hours and they said I couldn't finish it".

I often hear about "emergency sections" that take 20-60 minutes to prep. A TRUE emergency section takes less than 10, and closer to 5, to truly do. OBs are TRAINED surgeons and they are GOOD at it! If they NEED to get that baby out, they WILL!

But after learning more about the obstetrics in our country, I'm coming more and more to believe most of the moms when they say it was an emergency.

With one little exception: I believe most of them are PREVENTABLE emergencies. I actually do believe that interventions or a lack of knowledge on the birth team's part probably did lead to a point where the OB on call would NOT have been able to deliver a healthy baby normally/naturally/vaginally. At that point, it is safer for the OB to do what they are trained to do (surgery) than mess about with something they (often) know little about (normal, vaginal, natural birth). I imagine now, when I hear these stories, that the OB just gets to a point that they are suddenly in uncharted waters again (normal birth) and realize that if they let the mom go another 1 1/2 hours it'll be bad, so they schedule a section for 45 minutes and they're good, baby & mama are safe, and life goes on.

So for me it makes me more passionate about informing both parents and our medical community, so we can stop doing things or allowing things to be done to us that LEAD to unnecessary emergency c-sections.

Because, while they may be emergencies to that OB in the next 1-2 hours, they more often than not are preventable. And who wouldn't be on board with preventing major surgery if it wasn't necessary?

I also want to do a shout out to all the VBAC mamas. You are all amazing and I stand and applaud you. Keep telling more mamas about your strength and information. YOU are changing the face of our birth culture.

natters said...

I was just reading an article on pubmed that is somewhat relevent.

"Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children."

not directly to do with EFM but it does state that there hasn't been significant improvements in neonatal mortality and maternal mortality has actually gotten worse as a result.

Louellena said...

"One of the problems with the continuous monitoring is the lack of communication between the birth team and the parents. Mom is monitored from down the hall, and when a nurse does walk in, she tends to look at the monitor and not the laboring woman. Another problem is obvious: mom can't move around and help her baby out. The baby is left to figure it out on his/her own." <-- This, totally. Well, the nurse was in the room the whole time but all she *did* was pay attention to the monitor and not even... more like, pay attention to teaching the intern how to *use* the monitor. 8-S The OB made decisions that were harmful - and he didn't even pay attention to me - just the monitor too. EFM - never again. OB-care - also never again. (unless *I* feel there's something wrong; I trust my baby far more than any monitor or OB or nurse)

beccalouise said...

I am really enjoying your blog. When I had my baby they told me the electronic monitoring externally was not picking up a heart beat well. What, faint or no heart beat? Scary! Without even an explanation a nurse shoved her hand up me to screw an internal monitor into my baby's scalp. I was also given pitocin though an IV without permission to "keep things moving". I was so scared by giving birth for the first time and by what they were doing to me, my blood pressure went up for the first time ever in my pregnancy and they had to give me magnesium(?) and that made it hard to move at all. When I tried to get up to shower the next day I blacked out because of it. Don't get me started on the nipple shield one helpful nurse started me on! I am trying to psych myself up for a more natural birth for the second one. I have a hard time thinking I can birth without a doctor, even though the facts add up that I can.

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