Will new fetal monitoring guidelines reduce number of Cesareans? July 30, 2009

If you are an expectant mother who would like to avoid the pain and extended recovery time attendant with an unnecessary Cesarean surgery as well as reduce your hospital bill, make sure your obstetrician knows about the new fetal monitoring guidelines published by the American College of Obstetricians and Gynecologists.

If you give birth in America, chances are good your doctor will use a fetal monitoring device during delivery. In fact, doctors use fetal monitoring devices in more than 85 percent of births in this country. They do this despite any evidence the devices are beneficial in any way.

“Honestly, the technology got rolled out before we knew if it worked or not,” said one St. Louis obstetrician.

In use since the early 1970s, fetal monitors have failed to reduce the risk of either cerebral palsy or newborn deaths. In addition, fetal monitors have significantly increased the incidence of both Cesarean surgeries and forceps deliveries.

Cesarean surgeries are much more costly than traditional births and extend the new mother’s recovery time.

Fetal monitoring technology was supposed to reduce the risk of either cerebral palsy or newborn death by giving doctors early warning signs of when a baby was not receiving enough oxygen to its brain during child birth. The thinking was that the early warning would give doctors more time to take corrective action and save the baby from injury or death.

The flaw in that reasoning is that 70 percent of cerebral palsy cases are caused before labor begins. Only 4 percent of cerebral palsy is caused solely from a mistake during childbirth. The remaining 26 percent of cases are caused by a combination of factors that can occur before, during or after childbirth.

In summary, fetal monitoring has the potential to prevent only 4 percent of cerebral palsy children and it has failed to do even that. Physicians’ new understanding of the technology is not expected to result in a lower incidence of cerebral palsy, but hopefully it will result in a lower incidence of unnecessary, costly Cesarean surgeries.

The reason for such hope is that the new guidelines refine what once were two categories of fetal monitor data into three categories. Previously, data was categorized as “reassuring” and “nonreassuring” so doctors would err on the side of caution and often intervene in the “nonreassuring” cases when in fact the babies would have been perfectly healthy without intervention.

Now the categories are “normal,” “nonreassuring” and “abnormal.” The “normal” babies clearly do not require intervention like Cesarean surgery or forceps delivery. The new guidelines go as far as to say that “abnormal” babies do not require immediate intervention but should instead be quickly evaluated for other means of providing the baby with oxygen such as giving the mother oxygen, changing her position, treating her low blood pressure or ceasing the artificial induction of labor.

The “nonreassuring” category now calls for much more thorough evaluation of additional factors before doctors are encouraged to intervene. Previously, where a doctor was apt to intervene in “nonreassuring” cases based solely on the fetal monitoring data, the guidelines now call for doctors to “look at the entire clinical picture, not just the [fetal monitor data].”

The entire clinical picture includes things like the mother’s blood pressure, heart rate and temperature, what medicines she might have been given, the frequency of contractions and how fast labor is progressing.

Immediate delivery is discouraged by the guidelines so hopefully that will save future mothers from the pain and costs of unnecessary Cesarean surgery. Further refinements of the guidelines are expected to be released next year.