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CC BY 4.0 · Surg J (N Y) 2018; 04(01): e23-e28
DOI: 10.1055/s-0038-1632404
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Continuous Electronic Fetal Monitoring during Labor: A Critique and a Reply to Contemporary Proponents

Thomas P. Sartwelle
1   Deans and Lyons, LLP, Houston, Texas
,
James C. Johnston
2   Global Neurology Consultants, USA and Auckland, New Zealand
› Author Affiliations
Further Information

Publication History

23 October 2017

12 January 2018

Publication Date:
07 March 2018 (online)

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Abstract

A half century after continuous electronic fetal monitoring (EFM) became the omnipresent standard of care for the vast majority of labors in the developed countries, and the cornerstone for cerebral palsy litigation, EFM advocates still do not have any scientific evidence justifying EFM use in most labors or courtrooms. Yet, these EFM proponents continue rationalizing the procedure with a rhetorical fog of meaningless words, misleading statistics, archaic concepts, and a complete disregard for medical ethics. This article illustrates the current state of affairs by providing an evidence-based review penetrating the rhetorical fog of a prototypical EFM advocate.

Keywords

electronic fetal monitoring - cerebral palsy - medical ethics - journal of child neurology - Dr. Max Wiznitzer - Dr. Marc Patterson
 

  • References

  • 1 Nelson KB, Sartwelle TP, Rouse DJ. Electronic fetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence. BMJ 2016; 355: i6405
    PubMedGoogle Scholar
  • 2 Alfirevic Z, Devane D, Gyte GML, Cuthbert A. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2017; 2 (02) CD006066
    PubMedGoogle Scholar
  • 3 MacLennan A, Hankins G, Speer N. Only an expert witness can prevent cerebral palsy. Obstet Gynecol 2006; 8 (01) 28-30
    PubMedGoogle Scholar
  • 4 Costantine MM, Saade GR. The first cesarean: role of “fetal distress” diagnosis. Semin Perinatol 2012; 36 (05) 379-383
    CrossrefPubMedGoogle Scholar
  • 5 Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy--fact and fiction. Am J Obstet Gynecol 2003; 188 (03) 628-633
    CrossrefPubMedGoogle Scholar
  • 6 Donn SM, Chiswick ML, Fanaroff JM. Medico-legal implications of hypoxic-ischemic birth injury. Semin Fetal Neonatal Med 2014; 19 (05) 317-321
    CrossrefPubMedGoogle Scholar
  • 7 Badawi N, Keogh JM. Causal pathways in cerebral palsy. J Paediatr Child Health 2013; 49 (01) 5-8
    CrossrefPubMedGoogle Scholar
  • 8 Wiznitzer M. Electronic fetal monitoring: are we asking the correct questions?. J Child Neuro 2016; 32 (03) 344-345
    PubMedGoogle Scholar
  • 9 Sartwelle TP, Johnston JC. Cerebral palsy litigation: change course or abandon ship. J Child Neurol 2015; 30 (07) 828-841
    CrossrefPubMedGoogle Scholar
  • 10 MacLennan AH, Thompson SC, Gecz J. Cerebral palsy: causes, pathways, and the role of genetic variants. Am J Obstet Gynecol 2015; 213 (06) 779-788
    CrossrefPubMedGoogle Scholar
  • 11 Sartwelle TP, Johnston JC, Arda B. Electronic fetal monitoring, cerebral palsy litigation, and bioethics: the evils in Pandora's box. J. Pediatric Care. 2016; 2: 2
    PubMedGoogle Scholar
  • 12 MacLennan A, Nelson KB, Hankins G, Speer M. Who will deliver our grandchildren? Implications of cerebral palsy litigation. JAMA 2005; 294 (13) 1688-1690
    CrossrefPubMedGoogle Scholar
  • 13 Holt v. Secretary of the Department of Health and Human Services, No. 05–0136V, U.S. Court of Federal Claims, Office of Special Master. June 24, 2015
    PubMed
  • 14 Asad v. Continental Airlines Inc., 314 F. Supp. 2d 726 (N.D. Ohio 2004)
    PubMed
  • 15 Johnston JC, Sartwelle TP. The expert witness in medical malpractice litigation: through the looking glass. J Child Neurol 2013; 28 (04) 484-501
    CrossrefPubMedGoogle Scholar
  • 16 O'Callaghan M, MacLennan A. Cesarean delivery and cerebral palsy: a systematic review and meta-analysis. Obstet Gynecol 2013; 122 (06) 1169-1175
    CrossrefPubMedGoogle Scholar
  • 17 Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy. Executive Summary: Neonatal Encephalopathy and Neurologic Outcome. 2nd ed. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy. Obstet Gynecol 2014; 123 (04) 896-901
    CrossrefPubMedGoogle Scholar
  • 18 Sartwelle TP, Johnston JC, Arda B. Perpetuating myths, fables, and fairy tales: a half century of electronic fetal monitoring. Surg J (N Y) 2015; 1 (01) e28-e34
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Sartwelle TP, Johnston JC, Arda B. Electronic fetal monitoring, cerebral palsy, and medical ethics: nonsense of a high order. Med Law Internat'l. 2017; 17 (1–2): 43-64
    PubMedGoogle Scholar
  • 20 Vreeman RC, Carroll AE. Festive medical myths. BMJ 2008; 337: a2769
    CrossrefPubMedGoogle Scholar
  • 21 Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA 2012; 307 (01) 37-38
    CrossrefPubMedGoogle Scholar
  • 22 Prasad V, Gall V, Cifu A. The frequency of medical reversal. Arch Intern Med 2011; 171 (18) 1675-1676
    CrossrefPubMedGoogle Scholar
  • 23 Gartler SM. The chromosome number in humans: a brief history. Nat Rev Genet 2006; 7 (08) 655-660
    CrossrefPubMedGoogle Scholar
  • 24 Graham EM, Petersen SM, Christo DK, Fox HE. Intrapartum electronic fetal heart rate monitoring and the prevention of perinatal brain injury. Obstet Gynecol 2006; 108 (3 Pt 1): 656-666
    CrossrefPubMedGoogle Scholar
  • 25 Banta DH, Thacker SB. Historical controversy in health technology assessment: the case of electronic fetal monitoring. Obstet Gynecol Surv 2001; 56 (11) 707-719
    CrossrefPubMedGoogle Scholar
  • 26 Quilligan EJ, Paul RH. Fetal monitoring: is it worth it?. Obstet Gynecol 1975; 45 (01) 96-100
    PubMedGoogle Scholar
  • 27 Benson RC, Shubeck F, Deutschberger J, Weiss W, Berendes H. Fetal heart rate as a predictor of fetal distress. A report from the collaborative project. Obstet Gynecol 1968; 32 (02) 259-266
    PubMedGoogle Scholar
  • 28 Sartwelle TP. Electronic fetal monitoring: a bridge too far. J Leg Med 2012; 33 (03) 313-379
    CrossrefPubMedGoogle Scholar
  • 29 Molina G, Weiser TG, Lipsitz SR. , et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA 2015; 314 (21) 2263-2270
    CrossrefPubMedGoogle Scholar
  • 30 Clark SL, Nageotte MP, Garite TJ. , et al. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013; 209 (02) 89-97
    CrossrefPubMedGoogle Scholar
  • 31 Ellenberg JH, Nelson KB. The association of cerebral palsy with birth asphyxia: a definitional quagmire. Dev Med Child Neurol 2013; 55 (03) 210-216
    CrossrefPubMedGoogle Scholar
  • 32 Nelson KB, Ellenberg JH. Antecedents of cerebral palsy. Multivariate analysis of risk. N Engl J Med 1986; 315 (02) 81-86
    CrossrefPubMedGoogle Scholar
  • 33 Fahey MC, Maclennan AH, Kretzschmar D, Gecz J, Kruer MC. The genetic basis of cerebral palsy. Dev Med Child Neurol 2017; 59 (05) 462-469
    CrossrefPubMedGoogle Scholar
  • 34 Clark SL, Hamilton EF, Garite TJ, Timmins A, Warrick PA, Smith S. The limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. Am J Obstet Gynecol 2017; 216 (02) 163.e1-163.e6
    CrossrefPubMedGoogle Scholar
  • 35 Yang M, Stout MJ, López JD, Colvin R, Macones GA, Cahill AG. Association of fetal heart rate baseline changes and neonatal outcomes. Am J Perinatol 2017; 34 (09) 879-886
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 INFANT Collaborative Group. Computerised interpretation of fetal heart rate during labour (INFANT): a randomised controlled trial. Lancet 2017; 389 (10080): 1719-1729
    CrossrefPubMedGoogle Scholar
  • 37 Belfort MA, Saade GR, Thom E. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. A randomized trial of intrapartum fetal ECG ST-segment analysis. N Engl J Med 2015; 373 (07) 632-641
    CrossrefPubMedGoogle Scholar
  • 38 Cahill AG, Roehl KA, Odibo AO, Macones GA. Association and prediction of neonatal acidemia. Am J Obstet Gynecol 2012; 207 (03) 206.e1-206.e8
    CrossrefPubMedGoogle Scholar
  • 39 Safe Motherhood and Newborn Health Committee. FIGO consensus guidelines on intrapartum fetal monitoring. 2015. http://www.jsog.or.jp/international/pdf/CTG.pdf . Accessed February 8, 2018
    PubMedGoogle Scholar
  • 40 Carson GD. Don't just do something, stand there. J Obstet Gynaecol Can 2016; 38 (09) 791-792
    CrossrefPubMedGoogle Scholar
  • 41 Lear CA, Galinsky R, Wassink G. , et al. The myths and physiology surrounding intrapartum decelerations: the critical role of the peripheral chemoreflex. J Physiol 2016; 594 (17) 4711-4725
    CrossrefPubMedGoogle Scholar
  • 42 Clark SL, Meyers JA, Frye DK, Garthwaite T, Lee AJ, Perlin JB. Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. Am J Obstet Gynecol 2015; 212 (04) 494.e1-494.e6
    CrossrefPubMedGoogle Scholar
  • 43 National Institute for Health and Care Excellence. Intrapartum care for health women and babies. 2017. https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#monitoring-during-labour . Accessed February 8, 2018
    PubMedGoogle Scholar
  • 44 ACOG Committee on Obstetric Practice. Approaches to limit intervention during labor and birth. Number 687. February 2017. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth . Accessed February 8, 2018
    PubMedGoogle Scholar