ACOG Issues New Practice Bulletin on Continuous Electronic Fetal Monitoring
By Rachel Walden — July 9, 2009
This is going to be a long one, readers, so sit tight!
The American College of Obstetricians and Gynecologists (ACOG) has issued a new practice bulletin on continuous electronic fetal monitoring in labor. Given how thoroughly this practice has been embraced by obstetricians – it was used in more than 85% of births in 2002, up from 45% in 1980 – some readers may be surprised by the bulletin’s strong statements about potential harms of and lack of evidence supporting its use.
Continuous electronic fetal monitoring (cEFM) was introduced in the early 1970s in the hopes of reducing certain complications such as cerebral palsy or fetal death, which were believed to occur because the fetus wasn’t getting enough oxygen. However, these expected benefits were not demonstrated prior to cEFM becoming nearly ubiquitous in obstetrics. As a New York Times piece on the bulletin points out: “Continuous monitoring became a standard obstetrical procedure before studies could show if the benefits outweighed the risks, and without clear-cut guidelines on how doctors should interpret the findings.”
The authors of the ACOG bulletin explain that – in weighing the evidence now – the efficacy of cEFM should be “judged by its ability to decrease complications, such as neonatal seizures, cerebral palsy, or intrapartum fetal death, while minimizing the need for unnecessary obstetric interventions, such as operative vaginal delivery or cesarean delivery.” [emphasis added]
Because there are no randomized trials comparing cEFM with other monitoring methods, the benefits “are gauged from reports comparing it with intermittent auscultation” [periodic listening via stethoscope].
The report states that cEFM does not reduce the risk of perinatal mortality or of cerebral palsy. It is thought to reduce the risk of neonatal seizures by about 50%; these seizures are estimated to occur in about 1 in 500 neonates, with a good prognosis for most patients. On the risk side, the authors very clearly note that cEFM increases the risk of c-section, and the risk of vacuum and forceps operative delivery.
Given these findings – though with a caveat that current practices for frequency of monitoring may make it logistically difficult under some current models of labor management and hospital staffing – the bulletin states:
Given that the available data do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable in a patient without complications.
The old practice bulletin has already been withdrawn, so it’s difficult to compare exact changes, but an ACOG press release explains that “One notable update in the guidelines is the three-tier classification system for FHR tracings (print-outs of the fetal heart rate).” The authors defined three categories of tracings with specific clinical criteria for each; they are normal (no action required), indeterminate (further evaluation and surveillance needed), and abnormal (requiring prompt evaluation).
Interestingly, the guideline does not recommend immediate cesarean section for the Category III tracings. Instead, it indicates that initial evaluation and treatment may include discontinuation of labor stimulating drugs, cervical exam to check for things like umbilical cord prolapse, changing the woman’s position, monitoring her blood pressure, and assessment of uterine contractions. They further explain that “If a Category III tracing does not resolve with these measures, delivery should be undertaken.”
The authors also explain that “Our goal with the ACOG guidelines was to define existing terminology and narrow definitions and categories so that everyone is on the same page.” This may be necessary in part because providers may often interpret fetal monitor strips very differently from one another, as evidenced here:
For example, when four obstetricians examined 50 cardiotocograms, they agreed in only 22% of the cases. Two months later, during the second review of the same 50 tracings, the clinicians interpreted 21% of the tracings differently than they did during the first evaluation. In another study, five obstetricians independently interpreted 150 cardiotocograms. The obstetricians interpreted the tracings similarly in 29% of the cases, suggesting poor interobserver reliability.
Continuous fetal monitoring may have become commonly used in part because clinicians hoped to avoid malpractice judgments. If there is little agreement between clinicians looking at these tracings, and little evidence of fetal benefit, however, that rationale may need to be discarded. The NY Times piece points out that “Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit” – in other words, a technique that clinicians have widely adopted with the hope that it would protect them and their patients may instead have a negative effect on their careers, finances, and (last but not least) patients.
Overall, the practice bulletin agrees pretty well with what advocates (including OBOS) have been saying for some time, by addressing reducing women’s exposure to unnecessary procedures, clearly outlining the risks and lack of many assumed benefits of continuous EFM, suggesting that the high tech option isn’t always better, acknowledging that providers may err and vary, and providing the possibility of initial measures that don’t involve going straight to c-section. It’s too early to tell what the response to this ACOG bulletin might be (and further refinements are expected next year), but we’ll certainly keep an eye out for commentary – please leave yours in the comments.
Thank goodness ACOG finally realizes that the practice of cEFM is not good for moms and babies AND it is no good for them when it comes to lawsuits. I can’t wait for the benefits to show in terms of better outcomes, less surgical births, and freedom of movement for mothers.
Well, I’m happy to hear that the ACOG finally officially declared what we all have known for years anyway. Of course, they also officially declared that induction for suspected macrosomia was not appropriate years ago, and we see how well that turned out.
I have said it elsewhere, but I suppose it deserves to be said everywhere. My doctor insisted while I was trying to VBAC that I was going to cause my baby “cerebral palsy” because he was “tachycardic” (which he certainly was not, thank goodness I could read the monitor) — all because he wanted to perform a non-medically indicated repeat cesarean.
I fought off that doctor and delivered a 10 lb baby vaginally… no cerebral palsy. I never even got an “I’m sorry for trying to convince you you were hurting your baby.”
I have to wonder what he thinks of this. Does he even remember what he said/did to me? No, I’m sure he doesn’t.
FeministBreeder, I didn’t get into for this post, but there was also a line in this document calling the expectation that the cEFM can accurately predict CP “unrealistic” – apparently there’s a >99% false positive rate.
Oh, yes yes yes! This is so exciting.
The Agency for Healthcare Research and Quality has long held this position that cEFM was unwarranted and possibly detrimental.
cEFM tracings are used against doctors in malpractice cases, as far as I know. Since they are so variably interpreted, it is easy to get an expert to come in and find something on a strip that looks suspicious.
I’m perplexed by the attention given to this ACOG guideline change. Blogs and twitter have been buzzing that ACOG has put finally put their stamp on approval on intermittent auscultation, but in fact the language in the current guideline is identical to the language in the 2002 guideline. Nor is ACOG’s declaration that it is “unrealistic” to expect EFM to prevent cerebral palsy or perinatal mortality new. Again, the language is identical between the two versions. The main difference (as far as I can tell, the only difference) is the incorporation of the latest NICHD changes to the terminology used to describe EFM patterns. These changes amount to calling “uterine hyperstimulation” “tachysystole” (maybe so women can’t understand what their care providers are talking about? Why use a relatively easy-to-understand term when you can go for one that is completely foreign even to most clinicians?) The other change is categorizing overall EFM patterns as “category 1, category 2, or category 3”, again using completely nebulous language compared with the previous terms “reassuring” and “nonreassuring”. And to boot, according to ACOG, “an appreciable fraction” of EFM tracings will be “Category 2,” for which the management that will optimize outcomes is unclear.
ACOG even uses the same example to illustrate the low inter-observer reliability (“when four obstetricians examined 50 cardiotocograms, they agreed in only 22% of the cases…”) even though this study was conducted in 1985. They fail to mention that a similar study was conducted using the 1997 NIH guidelines, and results were equally disappointing. And the 1997 guidelines were also devised to standardize the language providers and hospital staff use. So much for that. (I summarized that study here: http://www.lamaze.org/LinkClick.aspx?fileticket=2drWyVEO4IA%3d&tabid=120&mid=566#A4)
I wrote a piece about the futility of “improving” EFM a few weeks back. Here’s that post http://www.scienceandsensibility.org/?p=212
By the way, Rachel, I completely don’t fault you for writing this piece. ACOG’s press release did suggest that the changes were more significant. And I think it’s completely disingenuous to remove from PubMed previous versions of clinical guidelines. I believe researchers and the public have a right to know what the guidelines and practice standards have been along the way. Do you know if it’s common practice for other medical societies to remove previous practice standards?
It turns out that there are indeed Prospective Randomized Controlled Trials done on EFM that go all the way back to the ’80s. By 1987 there were 8 or so of those “gold standard” trials published in authoritative journals in the US and Europe, including one from ’86, in the British Medical Journal, comparing EFM with intermittent listening, and all the studies were summarized in the Lancet, December 12, 1987 (the intermittent listening was done with fetascope or Doppler, and differences between those two methods were not distinguished). This meta-analysis showed unequivocal results, since all the studies came to the SAME CONCLUSION: EFM has only one constant and significant statistical effect: it increases the rate of cesarean section. The studies showed that there was no beneficial effect on fetal health, or on fetal outcomes. NONE. It does not identify more babies at risk than intermittent listening, or identify and save babies from CP, or turn compromised babies into healthy ones or save baby’s lives any more than simple intermittent listening. Therefore, the ratio of benefit-to-risk was negative in that it caused an increase in c-section without any benefit to mother or baby. Yet today and every day, EFM machines churn away in every L&D, and no laboring mother is ever told that it’s just fine to have someone just listen to her baby’s heart rate every half-hour, or that she can request, and indeed insist, that she have intermittent monitoring. And of course, no one ever tells her that if she stays connected to the monitor, her chances of c-section go up. Even more distressing is the fact that no matter how ACOG re-analyzes and renames and re-categorizes FHR monitoring, as in the new practice bulletin, they will never come out and say.”Don’t use continuous monitoring because it has proven negative consequences”…that pesky increase in the rate of cesareans. Here’s a really upsetting study published in the American Journal of Obstetrics and Gynecology that the Times will never mention: since obstetricians really couldn’t believe that observing every fetal heartbeat on a strip isn’t helping the health of babies, they thought that more training in interpretation of the monitor tracings would be the answer. So a study was done to find out if special training for obstetricians and perinatologists could reliably identify babies in trouble by using continuous monitoring. Here’s the citation in case you want to check it out: “Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: Interobserver variability”. American Journal of Obstetrics and Gynecology, doi 10.1016/j.ajog.2008.06.027[Abstract]. And here’s the conclusion of that study: even special extra training of experienced maternal-fetal medical professionals does not help predict or identify which babies would be compromised. It’s not just that they disagree because training is useless or because experts can disagree…it’s that they disagree because EFM is useless… or, as the researchers state: “intrapartum FHR (EFM) monitoring is not a useful diagnostic test…” If the effect of a procedure is neither neutral nor beneficial, if it has indeed been shown to have risk, i.e., lead to increased, and by implication, unnecessary c-section, how can the use of EFM on every woman every day in this country have any ethical justification. ACOG says, in Practice Bulletin #76, “Despite its widespread use, there is controversy about the efficacy of EFM. Moreover, there is evidence that the use of EFM increases the rate of cesarean and operative vaginal deliveries. Given that the available data do not clearly support the use of EFM over intermittent ausculation, either option is acceptable in a patient without complications.” (Obstetrics and Gynecology, Intrapartum Fetal Heart-Rate Monitoring 106 (6), 1463-1561.) They can remove what they like from their own prior literature, but Amy is correct in that they cannot erase the studies already out there for years. Is it ethical for ACOG even to call EFM an “acceptable option”? ACOG wants everyone “to be on the same page”? Maybe intermittent listening is the page all should be on!! Let’s not even begin to talk about “defensive” medical practices!
Amy, no worries – I never post on a topic like this without expecting some potential discussion and disagreement. My first instinct was also to pull a copy of the old version and compare line by line – unfortunately that was not possible, and I agree with you that this is a problem. I have seen other org guidelines that are not completely pulled, but are just edited with a prominent note that the guideline has been superseded by a new version – which I think is a much more appropriate and transparent strategy.
As to the reason I was personally interested in posting on this topic (and I try not to speak for OBOS when responding to this type of question, but just for myself) – I was aware that there was already research out there suggesting cEFM is not all it was cracked up to be, including the research the ACOG document cites. As the document reminds us, though, despite that research existing for some time, use of EFM has gone from 45% 30 years ago (before some of the research Jackie cites) to 85% now (and by “now” I mean 2002, but after research has been published questioning the benefits). Clearly, use has gone up and providers are not getting or internalizing the message that this practice and its ubiquity need to be questioned. That, I think, makes it important to publicize the ACOG statement, to inform and notify these providers that their practice is not necessarily consistent with the evidence or with their professional org (for many of them, anyway) – but more importantly to inform readers that this statement exists so they are armed with information if needed when encountering their own birth providers.
Side note: I do think the three categories are somewhat important as well, at the very least as a reminder to clinicians that not every blip warrants an immediate c-section, and to try to apply some consistency for those who are going to persist in using cEFM, considering the poor interobserver reliability in interpreting the tracings that the bulletin authors note. If they’re going to do it, I hope they could at least agree on what it means at some rudimentary level. But I’m a medical librarian by day, so I have an unusual appreciation for categories and definitions. 😉
The trick would be to
a) find a fetoscope in the hospital
b) find a nurse who knew how to use it
As long as there are nurses who have never used a non-electrical, non u/s listening device, ACOG won’t have an easy time changing back to the old ways. Even intermittent electronic monitoring is harmful to babies and has never been proven to improve birth outcomes.
I was at a Michelle Odent lecture several years ago and I’ve resurrected my notes, which are not complete for this topic, because this info came from a Q&A portion of the lecture. He said that the best results for baby’s health came from the hand-held “pocket doppler”, and he cited what he called a “very good” triangular study from Zimbabwe published in the BMJ, which was done to identfify the least expensive way of three, fetascope, cEFM or pocket doppler, to acheive the best results…in other words, did they have to buy those big expensive machines if the little ones were effective? I didn’t note the year of that study, but he went on to talk about a study from 1990 in the New England Journal of Medicine that was done on preemies, and even in this high-risk population, intermittant listening by pocket doppler had the best outcomes, and a follow-up on the babies at 18 months showed the most CP in the continuous EFM group. This is all just fyi, because as Amy and Rachel say, EFM rates have only risen, and practices are difficult/impossible to change unless, like thalidamide, there is glaring harm. How many organizations have grown up just to support and protect women’s bodies and their babies, and their rights to normal birth? All the private and public voices, and the people doing research and teaching best-evidence care must keep talking to each other and supporting each other, because gloom about the state of maternity care in our country lurks very near by. Anyway, Hi Amy from Jackie Levine.
Here is a good article and bibliography from the U.S. Preventative Services Task Force for anyone who is interested.
Well, thanks for the link to that article. I’ve spent many an hour in L&D’s on Long Island, NY, as a doula, and the consequences of cEFM are all too evident for some of the mother’s I support, but as a Lamaze educator, I make sure that every doula client of mine has abstracts and quotes and citations to bolster her refusals of cEFM, and the article you linked has some really juicy ones that I can use! And ACOG has a “Committee Opinion, #108” from 1992 on Informed Refusal which I found in a 2001 “Compendium of Selected Publications” on the “ethical dimensions of informed consent”. I’ll quote form it: “Once a patient has been informed of the material risks and benefits involved with a treatment, test, or a procdedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test, or procedure, or whether to make a choice among a variety of treatments, tests, and procedures”, and ” the informed patient has the right to refuse to undergo any of these treatments, tests or procedures.” Armed with information, our friends, our sisters, daughters and clients are beginning to refuse. The link you told us about is valuable in that light. So thanks.
Interesting conversation and hello Jackie from Amy! 🙂
Rachel, I agree that we need to publicize the fact that ACOG’s own clinical guidelines say that cEFM is an overused, harmful intervention and that a low-tech alternative is safe and effective. But ACOG has been saying these things for years and years now, and cEFM rates continue to rise (BTW, the 2005 rate of cEFM is 94% according to Listening to Mothers II). Looking at the guideline and press release give a sense of why this is true. The fact that intermittent auscultation is the safer method for the mother and just as safe for babies (barring significant complications in the labor) is given a few lines lip service, while the intricacies of how to interpret cEFM sprawls across multiple pages of the document. This leaves the reader believing that they’ve unlocked the key to making cEFM effective, which is utterly untrue.
Thanks MomsTFH for the link. I had seen that once upon a time but forgot it was out there.
Until hospitals are willing to provide staffing that allows for 1:1 nursing care during labor, with nurses trained to use intermittent manual monitoring, we will have EFM. I’ve worked L & D, and I’ve never even seen a fetoscope. It was normal to be assigned 2-3 laboring patients to monitor. And since most labors were inductions, or had Pitocin enhancement, it was hospital policy to monitor the heartbeat every 15 minutes minimum. With 2-3 patients, it would be well nigh impossible to to do this without EFM, as well as to complete the other nursing duties required. Until many of the hospital practices are changed- staffing ratios, inductions, pain management, use of Pitocin- EFM will simply not be going away.
I think its telling to see who is really upset about the changing guidelines for EFM –
the trial lawyers.
See link for an example
After reading the link above re malpractice, I was shocked to see the author tout monitoring as “risk free” (what have we all been talking about here…increased risk of Cesarean without increased benefit, which ain’t small potatoes) and non-invasive. He also states that Cesarean surgery is one of the safest surgeries around (so safe that our MMR is going up as the Cesarean rate goes up). All spoken like a true man who isn’t the one under the knife. I was at a conference the other day and the comment was made that any surgery which isn’t lifesaving is lifethreatening…radical but true if you read the tiny numbers in the stats.
I agree with the poster above that getting the nurses to cooperate with intermittent auscultation is a huge hurdle. At my hospital, if there are doughnuts and pizza in the nurses’ station kitchen, nobody is going to forego that to sit on a patient’s bed and listen to heart tones.
Hello, I am a seasoned labor and delivery nurse as well as a certified childbirth educator. I am proud to say I invented a soft disposable pad that is used directly on the external monitor. I believe that if we are monitoring pregnant woman we should at least make it a comfortable experience. the-addition is a soft latex free pad that provides a more comfortable experience as well as less adjustment for the provider, Please visit the website. Thank you
Just letting you know, the link to the acog press release no longer works. 🙁
But I love the article! Now I just wish I could find the acog current stance on this so I can take it to my doctor!
Whether or not intermittant listening is convenient for staff or whomever, here’s a little something from an obstetrics textbook(Obstetrics: Normal and Problem Pregnancies, 3rd ed, Gabbe, Niebyl, Simpson, p565).
“Despite dramatic advances in perinatal medicine, the widespread employment of electronic fetal monitoring, and a significant increase in the cesarean birth rate in the last three decades, there has been no reported reduction in the rate of cerebral palsy. There is general consensus that electronic fetal monitoring does not reduce the risk of metabolic acidosis-related newborn morbidity or cerebreal palsy better than intermittant auscultation”. And of course there’s that pesky rise in the c-section rate…
This quote cites among other sources, the ACOG Committee on Obstetrics, Technical Bulletin No. 163, Jan 1992, Washingtoin DC. You can surely take that to your doc…
‘@Brittini — thanks for mentioning it! I’ve updated the link with a new URL for the press release, which has been moved to here:
ACOG Refines Fetal Heart Rate Monitoring Guidelines
This is a useful article. I have been researching on the subject for a while and came across whattoexpect.com which talks about pregnancy and babies. Hope this helps your readers too.