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Dec152010

The “Big Brother” of Birth

Written on December 12, 2010 at 5:12 pm by Birth Sense

 

This month’s issue of Obstetrics and Gynecology contains a compelling commentary by Dr. David Grimes, entitled Electronic Fetal Monitoring as a Public Health Screening Program: The Arithmetic of Failure.  Dr. Grimes states,

“Electronic fetal monitoring has failed as a public health screening program. Nevertheless, most of the four million low-risk women giving birth in the United States each year continue to undergo this screening. The failure of this program should have been anticipated and thus avoided had the accepted principles of screening been considered before its introduction.” 

He goes on to describe how electronic fetal monitoring (EFM) has both a poor positive predictive value (PPV) and poor validity.  PPV is the likelihood that an individual is affected with a condition when a screening test says s/he is.  Validity refers to the likelihood that a diagnosis, such as fetal intolerance of labor, actually results in a baby who suffered intolerance of labor.  Dr. Grimes sums it up very concisely:  “Stated alternatively, almost every positive test result is wrong.”

Ironically, while Dr. Grimes and Obstetrics and Gynecology are lamenting about the failures of electronic fetal monitoring, a hospital in my state is preparing to up the ante by increasing their fetal heart rate surveillance–only this time, they will be adding remote monitoring, computerized interpretation of fetal heart rate patterns, and a ” big brother” overseer to step in when concerning heart rates are identified.  The remote monitor will allow physicians to view the fetal heart rate tracing from anywhere, on a variety of electronic devices without actually having to be at the patient’s bedside.  The computer will “interpret” the pattern and recommend a course of management. (Here I envision the monitor struggling to pick up a fetal heart rate after the baby has been born but the monitor belts have not been removed from the mother’s abdomen.  A tinny, robotic voice in the background intoning, “Fetal heart rate is zero.  Proceed to c-section immediately.  Rapid response team has been activated.”)

Finally, “big brother” is a clinical nurse specialist or experienced labor nurse who will observe monitor strips and electronic charting from a remote location, possibly managing several hospitals at one time.  S/he will intervene by notifying the labor and delivery charge nurse if s/he determines that appropriate, standard management is not being followed in a timely fashion.  What will this mean in practice?  The woman who pushes for two hours and has not yet had her baby is taken for a c-section, despite her provider’s protests that she is making progress and can deliver vaginally.  The patient who reaches 41 weeks but does not want to be induced will be coerced into an induction because it is the “standard of care”, regardless of her personal circumstances and wishes.  The midwife who heretofore has been able to encourage her patients to walk during labor, and choose the position they want to use for delivery, will be compelled to keep her patient in bed on continual monitoring.  Come on, now, you didn’t think they would spend millions for this service and then actually allow patients not to utilize it?

As expensive as it would be to provide a trained labor nurse for each labor patient, a nurse who stayed in the room attending to her patient for the duration of labor, it would be much less expensive than this new equipment will be.  The increased cost for the computers, monitors, remote overseers, and maintenance will far outweigh the cost of a one-to-one labor nurse for each patient.  How about doulas, provided by the hospital, one for each patient?  Proven to dramatically reduce the incidence of c-section, this is a service rarely, if ever, provided by a hospital.

One physician in my state voiced his protests over the brave new world of computerized interpretation of fetal heart tones (FHTs):

“Last time I checked, the cesarean rate was at about 1:3 women admitted to L&D.  With such a remote “overseer” in place, able to second-guess the front-line care providers, the opportunity for defensive medicine and “physician intolerance for labor” will predictably lead to even higher cesarean rates…with, as all studies have shown, no neonatal benefit and very real maternal morbidity, both short and long-term.  . .Then there are the medical-legal concerns… and again, incentive for “defensive” medicine and earlier decisions for cesarean section delivery.  We all can think of many FHT’s that have been transiently labeled “pathologic” or “problematic” only to yield a healthy newborn with no long-term sequelae, many of which can be delivered vaginally with patience and appropriate timely responses, by understanding the larger picture of clinical risk and relevant physiology.[Computerized EFM interpretation] would tend to make the FHT way too central in the clinical calculus of intrapartum management and has to potential for contributing to adverse maternal, if not fetal, outcomes.”

Change is coming.  If consumers of OB care do not speak out against the trend that modern obstetrics is taking, it may soon be too late.  The wholehearted adoption of EFM in the 70’s, despite no evidence that it produced better outcomes, is a clear warning of how hard it is to go back once technological advances have become standard of care.



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