Explaining the (Over)Use of Electronic Fetal Monitoring: Evidence From a Study of Work Flow on the Unit [14O

Abstract

INTRODUCTION: Guidelines from ACOG, AWHONN, and ACNM recommend against the routine use of electronic fetal monitoring (EFM) for low risk, healthy labors, recognizing the limited evidence of improved outcomes and its contribution to cesarean births. Yet the vast majority of healthy labors continue to be monitored with EFM rather than intermittent auscultation (IA). We explore the reasons for this disjuncture, going beyond the untested assumption that liability concerns drive EFM use to examine the place of EFM in the workflow of maternity care units. METHODS: A mixed methods study, at a large medical center, using 1) observations on the unit (121 hours), 2) interviews and focus groups with nurses, midwives, obstetricians, and administrators (n=47), 3) chart review, and 4) a short survey of care providers (n=140). RESULTS: Four areas favor EFM use: The work environment (incorrect assumptions about what others on the care team want; EFM as default order; economic and time efficiency); Patients (limited knowledge of monitoring options); Technology (emphasis on EFM training over other approaches); Fear (of missing something, of blame from colleagues, of litigation). CONCLUSION: In light of the recognition – by ACOG and other professional societies – of the role of EFM in the overuse of cesarean sections – it is imperative that we understand continued reliance on this technology. Our study – the first of its kind – points to practical steps needed to reduce this reliance, including open communication among maternity care team members, change in EHR order sets, training in use of IA, and patient education.