Electronic fetal monitoring is more important than freedom of maternal position in labour: FOR: Position in labour is important but EFM can be vital.

Abstract

There is universal acceptance (except perhaps by ‘free-birthers’) that there is a likely benefit from some form of fetal surveillance during labour. Currently, the choice is between intermittent auscultation and continuous electronic fetal monitoring (cEFM). Even intermittent ‘auscultation’ is commonly performed using a portable Doppler ultrasound fetal heart detector, the only sensible option if the mother is very obese. Although meta-analyses have shown a statistically significant 30% reduction in stillbirth attributed to asphyxia when cEFM is used rather than auscultation (Vintzileos et al. Obstet Gynecol 1995;85:149–55) and a statistically significant 50% reduction in neonatal convulsions (Thacker et al. Obstet Gynecol 1995;86:613–20), the 2014 UK National Institute of Health and Clinical Excellence guidelines still recommend intermittent auscultation for women ‘without risk factors’ (https://www.nice.org.uk/guidance/cg190). But how many women have/develop risk factors? I analysed 29 443 births from 1988 to 1998 at the West London/Chelsea and Westminster Hospitals and found that 74% had at least one risk factor where cEFM is recommended (maternal age ≥40, diabetes, cardiac or renal disease, antepartum haemorrhage, diastolic blood pressure ≥90 mmHg, non-cephalic presentation, induced or augmented labour, epidural anaesthesia, pyrexia, meconium staining of the amniotic fluid, or labour >12 hours). So in only 26% was cEFM not indicated at some time during labour. How important is posture in labour? I accept that the supine position should be avoided. Williams in 1952 illustrated the adverse effect on uterine activity of the supine position compared with sitting (frequency of contractions doubled and active pressure halved [J Obstet Gynaecol Br Emp 1952; 59:635–641]) and this was corroborated in 1960 by Caldeyro-Barcia (Am J Obstet Gynecol 1960;80:284–90), in 1978 by Turnbull (figure 4.11, Scientific Basis of Obstetrics and Gynaecology, 1978;79–108) and by my personal observations (unpublished). But does any particular position other than supine confer an advantage? Is gravity helpful? Mendez-Bauer suggested in 1975 that standing improved progress in labour, but his comparison was with the supine position (J Perinat Med 1975;3:89–100). When challenged to repeat the study comparing standing with lateral recumbency, he found no difference (Roberts et al. J Reprod Med 1984;29:477–81). In human childbirth, where the baby has to be pushed through a birth canal commonly smaller than the unmoulded fetal head, the driving force is uterine contractions, not gravity. This is elegantly demonstrated by the fact that labour in a birthing pool, where the effect of gravity is negated by the buoyancy of the water, has the same duration as labour on dry land (Cluett & Burns. Cochrane Database Syst Rev 2009;(2):CD000111). These data support the 2014 NICE recommendation that women should be discouraged from being supine but encouraged to adopt any other position they find comfortable. Some women value freedom to move, but in many cases, cEFM is vitally important, and with telemetry there is, in any case, no reason why maternal movement should be restricted. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.