Birth Preferences (Part 5): Fetal Monitoring

Photo by Sharon McCutcheon

(Originally posted on March 15, 2018, updated August 24, 2020)

A lot of families we support as doulas aren't aware that they'll likely have a choice when it comes to how their baby’s heart rate is monitored during labor, and don't realize how large an impact this choice can have on how a birth unfolds. So, what are the different types of monitoring, and which is best for you? Read on for a little background info that may help when discussing this important decision with your provider.

History of Electronic Fetal Monitoring

Electronic Fetal Monitoring as we now know it (think straps around the belly and continuous heart rate tracings recorded onto a strip of paper) is a relatively new-ish thing. Long story short, listening to fetal heart sounds as a way to determine fetal wellbeing started gaining in popularity in the 1800's- at which time the method was simply listening with one's ear next to a mother's abdomen. It wasn't until the early 1900's that the fetoscope was invented and intermittent auscultation (IA), a systematic method of listening to the fetal heart rate during labor, became widely recommended. IA remained the standard of care until well into the 1970's, when Electronic Fetal Monitoring, commercially introduced in the 60's, gained in popularity. It was also during the early 70's that the fetal scalp electrode used in internal fetal monitoring was introduced. (source)

Types of Monitoring

So, basically we have two major types of monitoring used today:

1) Electronic Fetal Monitoring  

• Sensors using doppler ultrasound onto the mother's belly for external monitoring of the fetal heart rate (usually continuously), held by either elasticized belts or a wireless patch system

-Or-

• A fetal scalp electrode, placed under the first layer of the skin on baby's head is used for internal monitoring of the fetal heart rate (always continuous, more precise, and often used in high risk situations)

2) Intermittent Auscultation

• A handheld doppler ultrasound transducer is used intermittently to listen to the fetal heart rate externally, every 5-30 minutes depending on risk status and stage of labor

What the Research Says

The interesting thing, as stated here, on an online EFM training module created by Howard Herrell, MD, FACOG, :

"Until recently, as new technologies have emerged, they have been adopted into clinical practice before large studies were carried out regarding their efficacies. IA was widely used for four decades before the first randomized clinical trials (RCTs) and EFM was used over a decade before the first RCT was available... Cochrane has published a meta-analysis comparing EFM to IA which showed no difference between the two in low Apgar scores, NICU admissions, perinatal deaths, or the development of Cerebral Palsy (CP). There was a 50% reduction in neonatal seizures, but a significant increase in operative vaginal delivery and cesarean delivery rates. Vintzeileos et al did show a reduction in perinatal death in the EFM group as compared to IA, on the order of one perinatal death prevention for every 1000 births, but with an associated increase in the cesarean delivery rate of 2-3 fold. Notwithstanding these controversies, EFM continues to be widely used today as a routine monitor of fetal wellbeing."

So why is continuous EFM still the standard of care, "despite evidence suggesting it is ineffectual, prone to interpretive errors, has a 99% false-positive prediction of fetal distress, has increased the incidence of cesarean delivery, has not reduced the rate of cerebral palsy (CP), and has not produced better perinatal outcomes", as this article states?

Well, per Evidence Based Birth, "until ACOG makes a clear statement that intermittent auscultation is preferable to EFM, obstetricians in the U.S. will probably stick with the status quo of EFM—even though the research evidence overwhelmingly supports intermittent auscultation, and this evidence has been around for more than 30 years now. The American College of Nurse Midwives openly disagrees with ACOG and says that intermittent auscultation– not electronic monitoring– should be the preferred method."

As it currently stands with ACOG, "Given that the available data do not show a clear benefit for the use of electronic fetal monitoring over intermittent auscultation, either option is acceptable in a patient without complications." (ACOG, 2009)."

Other Considerations

While many hospitals, including the SSM St. Mary's and UnityPoint Meriter in Madison, have portable EFM units allowing a laboring woman to remain mobile and even get into the tub, one downside to continuous monitoring is that is can sometimes create fear and distraction during a time when remaining calm and focused is really important in allowing birth to progress normally. It can be very difficult to get good tracing as the mother moves around or changes positions, requiring frequent interruption for adjustments to straps or wireless patches. It may also open the door for premature or unnecessary intervention. On the flip side, of course there are times when continuous monitoring is medically necessary, and some parents feel more reassured with continuous monitoring.

Bottom Line

As with all of the options you are faced with while exploring your birth preferences, you are in the driver's seat, and ultimately you should be given a choice in how your baby is monitored after being presented with the benefits and risks as they relate to your unique situation. It's super important that you have discussions about all your birth preferences with your provider before you go into labor to ensure you are on the same page, and the way your baby is to be monitored is one area you won’t want to miss.

See additional posts in this series:  Birth Preferences (Part 1): The Importance of Informed Consent and the "Overdue" Baby, Birth Preferences (Part 2): Vaginal Exams, Birth Preferences (Part 3): Birthing Environment and Choosing a Care Provider, and Birth Preferences (Part 4): Labor Coping Strategies

Written by Angie Traska, coordinator of Align Doula Services, providing intuitive, attentive doula support that aligns with you. Serving Madison, WI and the surrounding areas.

Want to meet a few excellent doulas, learn more about Align’s classes or other services? Please join us for our complimentary doula info meeting on  September 2nd to learn more, or shoot us a message to line up a private consultation!

Disclaimer:  The content found on this blog is meant only to provide general information and is not a substitute for professional medical advice.