The Monthly Doula
A newsletter by Birth a Miracle Services 

Volume 1 Issue 10 April 2009
Electronic Fetal Monitoring

Mission Statement: My goal is to educate and inform all parents and future parents of their rights and responsibilities of bearing children and of the truth and wonder of birth. My mission is to inspire them to enjoy their pregnancies and to look forward to bringing their children into the world.

Contents:
Letter from the Editor
In the News
Quote of the Month
Electronic Fetal Monitoring: Everything You Need to Know
Is Computerized Labor Monitoring the Future of Labor Assessment?
Website of the Month
Book of the Month
Online Video of the Month
What is Birth a Miracle Services?
Inspired Birth
Request for Contributions
Subscribing/Unsubscribing
Letter From the Editor
When a woman goes to the hospital to have her baby, she is first attached to an electronic fetal monitor machine. It is made of two straps that go around the abdomen and hold two electrodes which are connected by wires to a machine by her bedside. For at least 20 minutes, the woman’s contractions are timed and measured, and her baby’s heart rate is recorded, both printed onto a sheet of paper by the computer attached to the wires.
Some women find them reassuring, others find them a nuisance, but the important question is whether or not they are useful. The following articles will address those points. Most hospitals will say they require you to have a “20 minute strip” when you walk in the door, and again every 1 for 20 minutes. If a complication develops, or you are high risk to begin with, you are told you must have “continuous” fetal monitoring. In the end, you as the patient have the right to choose whether to use the monitor or not. The alternative, known as intermittent auscultation with a hand held Doppler, is also discussed in this newsletter.
As always, do your own research before you make a choice so that you are well-informed.

Enjoy!

Naomi Kilbreth, CD
Birth a Miracle Services
36 Greenwood Street
West Paris, ME 04289
(207) 754-8875
Kilbrethfamily@yahoo.com
www.birthamiracle.wordpress.com
In the News:
EFM doesn’t meet expectations: Admission electronic fetal monitoring did not decrease neonatal morbidity and mortality compared with intermittent auscultation. See the full article by Lancet here: http://findarticles.com/p/articles/mi_m0689/is_6_52/ai_104079668/

Contrary to hope: The most widely supported belief was the EFM would prevent cerebral palsy, but it turns out, it does no such thing. See the full story here: http://www.collegeofmidwives.org/colle4/temporary02/IntervewBackgd_Aug05.htm

Grasping onto hope: Small study finds that women attempting a vaginal birth after cesarean (VBAC) may have more of a chance if they use intermittent auscultation instead of continuous EFM. See the discussion here: http://www.lamaze.org/NormalBirthForum/tabid/363/forumid/14/postid/30863/view/topic/Default.aspx
Quote of the Month:
“There have been 12 randomised trials so far, the results of these show that in low risk pregnancies, EFM offers no added benefit over intermittent auscultation. Meta-analysis 3 of published randomised controlled trials (RCT’s) comparing the efficacy and safety of EFM with intermittent auscultation revealed an increase in maternal morbidity due to a higher incidence of caesarean sections (CS) and operative vaginal delivery. The risk of a CS delivery was the greatest in low risk pregnancies.” ~ A. Sinha and S. Arulkumaran, http://www.obgyn.net/women/women.asp?page=/firstcontroversies/prague1999sinha-arulkumaran2
Electronic Fetal Monitoring: Everything You Need to Know
By Naomi Kilbreth

Electronic Fetal Monitoring is a form of listening to your unborn baby’s heartbeat and to measure the strength of your contractions. Two straps are wrapped around your belly that have doppler-like instruments attached. These instruments send measurements to a machine, which then records the information received on strips of paper, which are kept with your chart after the birth. The use of EFM became widely popular among hospitals in the 1970s, without proper testing and research on its use. EFM quickly replaced intermittent monitoring by nurses with hand-held dopplers or fetoscopes.
There are two very big reasons why EFM became so popular, although I’m sure there are many more. One is that a “strip” from the machine is hard proof of the progress of your labor; with it, physicians can defend themselves in court should a patient decide that the caregiver made a mistake while caring for her. Judges will more likely rely on this information rather than a handwritten chart provided by the nursing staff. Two, a hospital that routinely uses EFM requires less staff, since one nurse can monitor many patients at the nurse’s station. Less staff requires less cost to the organization, which leads to a more stable income for the head employees of the hospital.
Generally, when a woman questions the purpose of the monitor, she will be told that it is to protect her and her baby, and that they are less likely to suffer injury or death with “proper monitoring”. The hospital managers do not tell them about the physician’s fear of malpractice suits or the concern over budget. Women and their families are also given a lack of information concerning research and statistics like the ones provided
below. Here are what a few medical professionals have to say about EFM:

“In most hospitals, doctors use fetal monitors routinely, although one study of 70,000 pregnancies found no difference in outcome between monitored and unmonitored patients, and other studies have shown that monitoring results in an increase in infant mortality among patients monitored.” (How to Raise a Healthy Child … In Spite of Your Doctor, Robert Mendelsohn, MD. 1984)

“Williams Obstetrics (the most widely used textbook in the U.S.) says, “an equally satisfactory outcome for the fetus can be achieved without continuous electronic fetal monitoring of the fetal heart rate, continuous intrauterine pressure recording and fetal scale measurement, if the mother and fetus are closely attended by appropriately trained labor room personnel.” (A Wise Birth, Penny Armstrong, CNM and Sheryl Feldman, 1990)

Using an EFM system also leaves room for disagreement over the treatment of a particular case. Sheila Kitzinger describes a study where four obstetricians were asked to examine the same fetal traces and to determine if it was necessary to deliver immediately. Surprisingly enough, they only agreed in one out of five cases1.

“EFM has increased the cesarean rate with no increase in fetal wellbeing.” (ACOG, 1996)

The CBE Reporter indicated that broad studies had been done, “showing no difference in fetal outcomes using either IA [Intermittent Auscultation] or EFM”. (CBE Reporter, 2000)

“This ubiquitous machine has not been associated with any noticeable lowering of infant mortality. Research done since then shows that intermittent listening with a fetascope [or doppler] is every bit as good at detecting a baby who is in trouble from lack of oxygen. From the mother’s standpoint, intermittent listening is far better – less painful and less likely to lead to ineffective labor and cesarean section.” (Ina May’s Guide to Childbirth, Ina May Gaskin, 2003)

Another issue related to EFM that is often downplayed or ignored altogether, is its effect on the type and amount of support that women receive while in labor. I have witnessed myself how easy it is for the doctor or midwife, nurse and even the husband and labor coach to be drawn the EFM screen. Instead of asking the mother how she is feeling or if the contraction has ended, they stare at the screen and don’t bother talking to the mother. Not only does EFM leave the mother feeling alone and unnecessary in her endeavor, but it also prevents her from adopting optimal postions for moving the baby into and through her pelvis.
Therefore, in most instances, it would be wise for a woman to request a fetascope or handheld doppler during her labor. She will be more comfortable out of bed, and she will inevitably receive more humane care, rather than from a machine.
Every woman has the right to use EFM, either continuously or intermittently. On the same hand, every woman has the right to information concerning the benefits and risks to each. If you have concerns about its use, use the information provided here to discuss with your caregiver its necessity for your particular pregnancy, labor and birth.
And of course, I highly recommend you to do your own research on procedures that are likely to be used on you or your baby. This will reasure you that you are getting the correct information, and that which is necessary to provide true informed consent to those procedures.

More resources
1 – “Homebirth” by Sheila Kitzinger, 2000

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Is Computerized Labor Monitoring the Future of Labor Assessment?
By Naomi Kilbreth

All women who have given birth with a birth attendant present are familiar with the standard method for determining cervical dilation and position of the baby’s head during labor: a manual vaginal exam every 1-4 hours until the child is born. However, there is a new piece of equipment on the market which may change hospital labor monitoring as we know it.
In 2001, an Israeli obstetrician decided that with all the technology available for childbirth, there had to be a way to create a machine that would accurately determine the same factors as a vaginal exam1. In 2007, he and his team finally received FDA approval for the “Barnev Computerized Labor Monitor” (CLM for short) in the active stage of labor, and began marketing it to hospitals across the USA2.
The CLM equipment consists of a doppler placed on the abdomen, two censors attached to the cervix, and one sensor attached to the baby’s scalp. The information is then displayed on easy to read screens next the patient’s bed and in the nurse’s station.
According to the Barnev company, over 300 women participated in a trial of the CLM, resulting in the following alleged benefits: a faster, simpler, and less painful way to determine cervical dilation and fetal position, freedom to use Pitocin or an Epidural, freedom to have a ‘natural’ childbirth, quicker treatment of fetal distress, CPD, failure to progress, and other labor complications3. Other reported benefits include cost effective management of labor, a legitimate defense for care providers experiencing lawsuits4, less unnecessary cesarean sections, forceps and vacuum extractions5.
What the press releases have not stated is that there are moderate risks involved with the CLM, as classified by the FDA. These risks include: patient injury, electrical hazards, ultrasound tissue damage, electromagnetic interference and electrostatic discharge hazards, mismanagement of patient, adverse tissue reaction, and infection6.
Other considerations that have not been discussed include the risk associated with rupturing the membranes, which is necessary to insert the electrode into the baby’s scalp, the potential for increased discomfort, and intervention if the CLM restricts the patient to her hospital bed. It is necessary for further studies in these areas to be conducted before the CLM can be freely used on all women.
In fact, some of the midwives originally involved in the CLM clinical study were removed from the program because of their strong hesitancy in such use of technology. One of the midwives told Midwifery Today that she believes “this product takes advantage of and potentially harms women and their babies in labor, all for the purpose of economically profiting a biotech company”7.
Although computerized labor monitors offer many benefits, use of manual vaginal examination still gives all necessary information to the care provider. Together with the lack of studies necessary for appropriate use of CLM, it may be wise for women to temporarily question its use when the equipment comes to their hospital.

Sources:
1 – Article by Avi Hein. Feb 14, 2007. www.stepstrategy.net/artman/publish/article_2687.shtml
2, 3 – Barnev, Inc. www.barnev.com/?CatagoryID=163
4 - www.obgyn.net/fetal-monitoring.asp?page=/news/computerized_labor_monitoring
5 – www.trigmed.com/index.php
6 – “Guidance for Industry and FDA Staff – Class II Special Controls Guidance Document: Computerized Labor Monitoring Systems” U.S.D.H.H.S. Food and Drug Administration. April 24, 2007
7 – “Postdate Pregnancies”. Midwifery Today E-News. Vol 8, Issue 11

2009 © Associated Content, All rights reserved. 
Privacy Policy | Terms of Use
Website of the Month:
http://www.aafp.org/afp/990501ap/editorials.html
Book of the Month:
Active Birth: The New Approach to Giving Birth Naturally, Revised Edition by Janet Balaskas (1992)
Online Video of the Month
http://www.youtube.com/watch?v=YNJZ1wyTf4U
What is Birth a Miracle Services?
Birth a Miracle Services is the name of the birth doula and childbirth education service that I started in 2002.
A birth doula is a person who offers informational, physical, emotional, spousal, and advocacy support to women through pregnancy, birth, and the early postpartum period. I also offer traditional childbirth preparation classes, birth art classes, and childbirth counseling.
All of this is available to women within an hour of my home in West Paris, Maine for a sliding scale fee. Single, teen, and low-income moms can receive my birth doula support for free.
For more information visit my blog: http://birthamiracle.wordpress.com/
Inspired Birth
I am proud to announce the birth of my first book, Inspired Birth: A Fresh Perspective for Christian Maternity Care Providers. It is an inspirational guide for all Christians who attend women in childbirth, with fresh ideas on how to meet the emotional and physical needs of childbearing women while addressing current challenges to American maternity care. This book is still in the editing process and is not currently available for purchase, but if you know any Christians who are doctors, nurses, midwives, or doulas, please let them know that this book is on the way!
Request for Contributions
Next month’s topic is prenatal testing. If you have anything you would like to contribute, such as your reasons for accepting or denying prenatal testing options, please email your thoughts with the subject line “Monthly Doula” to Kilbrethfamily@yahoo.com . Thank you!
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To view previous issues of The Monthly Doula, click this link: http://birthamiracle.wordpress.com/category/the-monthly-doula/

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