Continuous Electronic Fetal Monitoring Research Articles

Pregnant women\u2019s clinical characteristics, intrapartum interventions, and duration of labour in urban China: a multi-center cross-sectional study

BackgroundThere is an increasing global trend towards the widespread over-medicalisation of labour and childbirth. The present study aimed to investigate pregnant women’s clinical characteristics, intrapartum interventions, duration of labour and its associated factors; and to compare the differences of these variables between nulliparas and multiparas in China.MethodsA multi-center cross-sectional study was carried out in three tertiary hospitals of Fudan University in Shanghai, China. A total of 1523 participants were approched and assessed for eligibility. Data on women’s sociodemographic characteristics, intrapartum interventions, and duration of labour were measured and collected. Kaplan-Meier survival analysis was performed to present the curves of total duration of labour by parity. After z-transformation of labour duration, multivariable linear regression was used to control for confounding and to identify independent associations between potential associated factors and the primary outcome of labour duration.ResultsOverall, 1209 eligible women agreed to participate and were investigated. Rates of different intrapartum interventions were 27.4% in use of amniotomy, 37.9% in use of oxytocin, 53.0% in continuous electronic fetal monitoring, and 52.9% in epidural use, respectively. The curve of total duration of labour was significantly different between nulliparas and multiparas (P < .001). Of the 1209 participants, 983 (81.3%) women eventually achieved successful vaginal birth while 226 (18.7%) women ended in intrapartum caesarean section. The median duration of total stage of labour was significantly longer in the nulliparous group [9.38 (6.33,14.10) hours] than that in the multiparous group [5.08 (3.00,7.83) hours] (P < .001). The following factors were independently associated with longer duration of total stage of labour: epidural analgesia (P < .001), primiparity (P < .001), continuous electronic fetal monitoring (P = .035), and increased birth weight (P = .005).ConclusionsIntrapartum medical interventions become common obstetric practices in urban China. Multifactorial variables independently associated with longer duration of labour were identified, including epidural analgesia, primiparity, continuous electronic fetal monitoring, and increased birth weight. Further research is required to validate these variables and to determine the modifiable factors for labour management. And models of care with lower intervention rates such as midwife-led models of care should be developed and implemented in China.

Assessment of Strategies for the Reduction of Cesarean Section Rate in Iranian and Foreign Studies: A Narrative Review

Objectives: This study was conducted aiming at exploring strategies for reducing cesarean section (C-section) in Iranian and foreign studies. Materials and Methods: The present study was carried out using a matrix approach and searching keywords including "Cesarean", "Effective Intervention", and "Cesarean Section Reduction Strategy" to find studies (2000-2019) in databases such as PubMed, SID, Science Direct, Google Scholar, and WHO. Results: CS reduction strategies were classified into 3 categories of psychological, clinical, and structural-policy interventions. The first category supports women throughout labor and childbirth by the midwife, doula, coping skills with fear and pain of labor, changes in the attitudes of service providers and pregnant women. Clinical interventions include vaginal birth after CS, vaginal breech delivery, external cephalic version (ECV) for breech presentation, encouragement of service providers into intermittent auscultation for the fetal heart rate instead of continuous electronic fetal monitoring (EFM), and training of service providers, pregnant woman, and her family. The last category encompassed managing insurance and financial services, receiving one-to-one care and midwifery care throughout active labor, and updating policy of labor induction in post-term pregnancy, as well as women’s admission policy with cervical dilatation of more than 4 cm with regular uterine contractions, active team care in labor, and auditing and feedback. Conclusions: It seems that multi-dimensional interventions are required to reduce the CS rate. Concerning some of the strategies (e.g., ECV), it is suggested that further research should be performed by addressing the limitations and drawbacks of previous studies before applying clinical procedures due to contradictory results.

Electronic Fetal Monitoring to Prevent Fetal Brain Injury: A Ubiquitous Yet Flawed Tool

(JAMA. 2019;322:611–612) The practice of fetal cardiac rate monitoring began in the 1830s or earlier, and guidelines for intermittent auscultation came out in the 1920s and remained largely unchanged until the 1970s, when continuous electronic fetal monitoring (EFM) appeared. EFM generates a visual recording of fetal heart rate using either Doppler wave technology or a contact electrode on the fetal scalp. Fetal acidosis is associated with abnormal heart rhythms, including tachycardia, bradycardia and transient decreases in pulse rate, as well as diminished variability. Variability cannot practically be detected with auscultation.

The Yield of Intraoperative Fetal Monitoring During Nonobstetric Surgery [34K

INTRODUCTION: While ACOG supports indicated surgery for pregnant patients, there is no clear consensus on optimal fetal monitoring for such cases. We examined whether continuous intraoperative electronic fetal monitoring (ciEFM) for nonobstetric surgeries after viability impacts decision for obstetric intervention and subsequent perinatal outcomes. METHODS: IRB approval was obtained for this retrospective cohort study conducted at a single academic center between January 2013 and March 2019. Demographic and outcome data were compared between ciEFM vs pre/post-procedure EFM. Multiple logistic regression was applied to adjust for clinical covariates. RESULTS: Of 1,060 cases reviewed, 43 (4.1%) were performed after viability (gestational age (GA) range: 23.7 to 36.4 weeks). ciEFM was used in 24 cases (56%). Two cases required intraoperative resuscitation in the ciEFM group, one with fluid bolus and one with emergent delivery (P=.49). ciEFM cases lasted longer (105 vs 40 minutes, P&lt;.01) and were more likely to be performed under general anesthesia (83.3% vs 26.3%, P&lt;.01). ciEFM had no association with non-reassuring postoperative EFM (18.2% vs 15.4%, P=1.00), postoperative tocolytic use (29.2% vs 10.5%, P=.26), or GA at delivery (37.1 vs 37.2, P=.92). There was no association on the rate of preterm delivery when adjusted for type, or length of surgery, and type of anesthesia (aOR 1.82, 95% CI 0.20-16.4, P=.59). CONCLUSION: ciEFM does not significantly affect intraoperative or postoperative obstetrical outcomes. This data can help obstetric providers allocate limited resources, reassure other surgical providers, and appropriately counsel patients who are about to undergo nonobstetric surgery.

Category II Fetal Monitoring in Fetuses With Congenital Heart Defects: Are They Any Different? [06O

INTRODUCTION: The majority of literature investigating continuous electronic fetal monitoring (EFM) excludes anomalous fetuses. The objective of this study was to determine if Category II EFM characteristics differed between fetuses with and without congenital heart defects (CHD). METHODS: This was a retrospective IRB-approved cohort study of singleton, term pregnancies admitted for induction or labor with an antenatal diagnosis of fetal CHD between 2017–2019. We excluded fetuses with genetic abnormalities. Cases were matched by race and obesity in a 1:2 ratio to a historic control of term pregnancies with structurally normal fetuses. EFM characteristics in the 1 hour before delivery were extracted. The primary outcome was incidence of Category II EFM features; secondary outcome was total deceleration area (TDA). RESULTS: 47 cases of fetal CHD were matched to 94 controls. There was no difference in advanced maternal age, other baseline demographics, or mode of delivery between groups. Fetuses with CHD were less likely to have prolonged decelerations (6.4 vs 25.5%, P&lt;.01) or any periods of tachycardia (4.3 vs 17.0, p 0.03) compared to normal fetuses. Other Category II features were similar between groups including incidence of recurrent late and variable decelerations and minimal variability. There was no difference in TDA between groups. CONCLUSION: Prolonged decelerations and tachycardia were less common in CHD fetuses. The incidence of other Category II features were similar to nonanomalous fetuses. These results suggest that structural heart defects do not increase the risk of concerning EFM patterns. Future studies should evaluate the risk of acidemia with Category II EFM and CHD.

The future of electronic fetal monitoring.

Continuous electronic fetal monitoring (EFM) was first introduced commercially over 50 years ago with the hope of improving perinatal outcomes during labor. However, despite the increased use of EFM, definitive improvements in perinatal outcomes have not been demonstrated. Variance in tracing interpretation and intervention has led to increased rates of cesarean and operative vaginal deliveries and perhaps increased maternal and neonatal morbidity. Since its inception, several strategies have been developed in hopes of optimizing EFM and improving these outcomes. We discuss the current standards of intrapartum fetal monitoring and review optimization strategies and technologies in development to improve intrapartum fetal monitoring.

Computerized Analysis of Intrapartum Fetal Heart Rate Patterns and Adverse Outcomes in the INFANT Trial

(Abstracted from BJOG 2019;126:1354–1361) During the 1960s and 1970s, intermittent auscultation was replaced by the alternative method of continuous electronic fetal monitoring (EFM) and cardiotocography (electronic monitoring of the fetal heart rate [FHR] and uterine contractions, or CTG). Meta-analyses have reported a 59% drop in intrapartum deaths attributable to hypoxia and a reduced risk of neonatal seizures, but a 2017 Cochrane review concluded that while EFM did reduce the rates of neonatal seizures, it did not provide “clear differences in cerebral palsy, infant mortality, or other standard measures of neonatal well-being.” Human error in interpreting the FHR pattern is a possible explanation for the ineffectiveness of EFM.

Access and outcomes of general practitioner obstetrician (rural generalist)-supported birthing units in Queensland.

ObjectiveTo describe characteristics and outcomes of women birthing within GP‐obstetrician (rural generalist) supported rural (level 3) obstetric units in Queensland.DesignRetrospective descriptive study.Setting21 GP‐obstetrician supported birthing units in Queensland.ParticipantsWomen (n = 3111) birthing from January 2017 to December 2017.Main outcome measuresPatient, pregnancy and labour characteristics and key maternal and neonatal outcomes routinely recorded in the Queensland Perinatal Data Collection and Queensland Hospital Admitted Patient Data Collection were compared to Queensland public hospital aggregate data.ResultsWomen birthing in rural maternity units were significantly more likely to be Aboriginal or Torrs Strait Islander (16% v 9%), < 20 years old (7% v 4%), term deliveries (96% v 91%), achieve spontaneous onset of labour (67% v 51%), and birth (71% v 60%) (p<0.001) compared with all Queensland public hospitals. They were significantly less likely to be nulliparous (36% v 40%), use pharmacological analgesia (65% v 69%), or have continuous electronic fetal monitoring in labour (54% v 66%) (p<0.001). Neonatal outcomes were comparable; with no significant difference in stillbirth rate between rural units and all Queensland public hospitals (4.8 v 7.3 per 1000 births). Precipitate delivery was the most common labour complication (36% v 33%) (p<0.001).ConclusionGP‐obstetrician (rural generalist) supported rural birthing units in Queensland provide important access for low and medium risk women to deliver locally, with strong indicators of quality and safety.

Maternity Providers' Perspectives on Barriers to Utilization of Intermittent Fetal Monitoring: A Qualitative Study.

There are 2 approaches to fetal assessment during labor: continuous electronic fetal monitoring (EFM) and intermittent auscultation (IA). The vast majority of healthy labors in the United States use EFM, despite professional organization recommendations against its use for low-risk pregnancies. This qualitative investigation explores maternity care team members' perspectives on why EFM is the dominant approach to fetal assessment instead of IA. Focus groups comprised of nurses, midwives, and physicians were conducted using a semistructured interview guide. Transcripts were analyzed using directed content analysis to identify themes related to clinical and nonclinical factors influencing the type of fetal assessment employed during labor. Seven focus groups with a total of 41 participants were completed. Seven themes were identified: clinical environment; technology; policies, procedures, and evidence-based protocols; patient-centered influences; fear of liability; providers as members of healthcare team; and deflection of responsibility. All maternity care team members had knowledge of the evidence base supporting IA use for low-risk care. Nurses identified unique challenges in having agency over monitoring decision making and executing best practices. Improved communication among team members can facilitate evidence-based approaches to IA use, facilitating increased utilization for low-risk labor care.

Effect of Nursing Interpretation and Intervention of Intrapartum Cardiotocography on Pregnancy Outcomes

An important goal of intrapartum monitoring is preservation of fetal well-being by early detection and relief, when possible, of those conditions causing fetal distress and adverse outcomes. The aim: Assess the effectiveness of nursing interpretation and intervention of intrapartum cardiotocography on pregnancy outcomes. Design: Quazi experimental design. The sample: Was convenient sample of 120 cases divided into two groups (study, and control) each one is 60 cases (30 low risks, and 30 high risks). Tools: three different tools namely assessment sheet for the mother in first stage includesall significant data about the mother, intrapartum fetal monitoring assessment will be done using cardiotocography strip, and Apgar score at one and five minutes. The settings: Shebin Elkom Teaching and University hospitals-Egypt. The main findings were that no statistically significant relations for low risk cases that being handled with cardiotocography and fetal complications. Instrumental delivery and cesarean section rate for low risk cases in the study group is increased than for low risk in control group shows statistical significance difference. There were strong statistically significant relations between high risk fetal heart rate nursing interpretation and Apgar score in the first minute. Statistical significance to total complications during present labor to the mother. Conclusion: Continuous cardiotocography should recommended for high-risk pregnancies where there is an increased risk of prenatal adverse outcomes. Cardiotocography for low risk is associated with a significant increase in instrumental delivery and caesarean section rates compared with intermittent auscultation. Recommendations: continuous electronic fetal monitoring should be recommended for high-risk pregnancies where there is an increased risk of fetal compromise.

Patterns of Admission Cardiotocography Decisions and Associated Perinatal Outcomes in a Southern Nigerian Teaching Hospital

Aims: To determine the patterns of obstetric decisions based on Cardiotocography (CTG) findings and the effect of these decisions on labour outcomes.&#x0D; Study Design: Retrospective observational audit.&#x0D; Place and Duration of Study: Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Remo. Data were obtained from all intrapartum CTG tracings done from January 2016 to December 2018.&#x0D; Methodology: A consecutive sampling technique was used and the case files, delivery register and follow up records of all included CTG tracings were used to obtain maternal and perinatal data. Data were analyzed using the SPSS version 21.0. Numerical data were expressed as mean ± standard deviation (SD). The Chi-square test was used to compare categorical variables while the independent T-test was used to compare means of groups studied. Binary logistic regression was used to assess the factors related to maternal and perinatal outcomes. The level of statistical significance was be set at p-value of &lt;0.05.&#x0D; Results: There were 756 deliveries, but only 436 CTGs met the inclusion criteria. The prevalence of abnormal CTG was 130/436 (29.8%); 93/436(21.3%) were suspicious while 37/436 (8.5%) were pathological. On the basis of CTG; 300/436 (68.8%) of the parturients had intermittent fetal heart tone auscultation, 100/436 (22.9%) had continuous Electronic fetal monitoring (EFM) while labour was stopped in 36/436 (8.3%). The 5th minute APGAR score did not depend on the admission CTG finding (0.55), the decision to stop or continue labour (p=0.26) or the use of continuous EFM (P=0.66). Maternal near miss (MNM) was not a consequence of the decision to stop labour (P=0.98) or the use of continuous EFM (P=0.19). The mode of delivery outcome was however a consequence of decisions to continue or stop labour (P &lt;0.001, AOR=0.202, 95%CI=0.153-0.265). Pregnancy risk was a consistent determinant of maternal outcomes; occurrence of MNM (P &lt;0.001, AOR=0.002, 95%CI=0.000-0.032) and mode of delivery (P &lt;0.001, AOR=0.015, 95%CI=0.005-0.043).&#x0D; Conclusion: Decisions based on admission CTG was associated with a high rate of operative deliveries, without any significant effect on fetal or maternal outcomes. CTG in labour should be restricted to pregnancies adjudged as high risk based on obstetric factors and CTG should be used as an adjunctive triaging instrument.

Continuous electronic fetal heart monitoring versus intermittent auscultation during labor: Would the literature outcomes have the same results if they were interpreted following the NICHHD guidelines?

All guidelines regarding electronic fetal heart monitoring (EFM) before 2008 were designed to avoid more hypoxia than acidosis. In addition, the results of the Cochrane meta-analysis of 2013 do not show a significant improvement in neonatal outcomes using EFM or intermittent auscultation (IA). We retrospectively evaluated the results on delivery outcomes arising from a comparison between EFM and IA during labor of 2 specific and high-quality trials. We hypothesized that revisiting the delivery outcomes through the adoption of the recent National Institute of Child Health and Human Development (NICHHD) guidelines, the reported delivery outcomes would be different. The study retrospectively evaluated the results on delivery outcomes arising from the comparison between EFM and IA during labor of the "Dublin trial" and "Vintzileos trial" published, respectively, in 1985 and 1993. A translational model was constructed to recalculate these results, applying a correction factor to estimate the number of pathological patterns using the NICHHD guidelines for EFM. After the reevaluation of the 2 trials using the proposed correction factor, the comparison of the recalculated cesarean section and operative delivery rates for fetal distress between EFM and IA group were no longer statistically significant, both in the Dublin trial and Vintzileos trial. Even the comparison of the recalculated incidence of the rate of non-reassuring fetal heart rate (FHR) patterns in the EFM and IA groups has not given any indication of significance for the Vintzileos trial. Our results lead to reconsidering the results of the Dublin trial and Vintzileos trial in terms of operational rates of births, hypothesizing that these results would have been significantly lower if FHR traces were interpreted using the current NICHHD guidelines, which aim to identify potential acidotic fetuses rather than hypoxic ones.

Healthy Birth Practice #4: Avoid Interventions Unless They Are Medically Necessary.

Maternity care in the United States continues to be intervention intensive. The routine use of intravenous fluids, restrictions on eating and drinking, continuous electronic fetal monitoring, epidural analgesia, and augmentation of labor characterize most U.S. births. The use of episiotomy has decreased but is still higher than it should be. These interventions disturb the normal physiology of labor and birth and restrict women's ability to cope with labor. The result is a cascade of interventions that increase risk, including the risk of cesarean surgery, for women and babies. This paper describes the use and effect of routine interventions on the physiologic process of labor and birth and identifies the unintended consequences resulting from the routine use of these interventions in labor and birth.

Impact of continuous electronic fetal monitoring on birth outcomes in low-risk pregnancies.

Continuous electronic fetal monitoring (CEFM) is a standard of hospital care during the intrapartum period. We investigated its use on childbirth outcomes in low-risk pregnancies, and examined whether outcomes differed by gestational age within a term pregnancy. A retrospective secondary data analysis using birth registry data from two diverse northeastern US states from 1992 to 2014. Chi-square test and the Fisher exact tests were used to examine associations between CEFM and childbirth outcomes. Multivariable Poisson regression models were used to estimate risk ratios of childbirth outcomes related to CEFM use, adjusting for potential confounders. Use of CEFM was independently associated with a 10% (State 1) and 40% (State 2) increased risk for primary cesarean delivery and an increased risk for assisted vaginal births (14% and 24%, respectively) after adjustment for confounders. CEFM use was not associated with reduced risk for infant mortality (neonatal mortality, 0-27days, and post-neonatal mortality, 28-364days) in term births (37-41weeks' gestation). After stratifying term pregnancies into early term, full term, and late term, use of CEFM was associated with reduced risk for neonatal mortality in early-term births (37 0/7weeks' to 38 6/7weeks' gestation) in State 2 (RR 0.44 [95% CI 0.21-0.92]), but not in State 1. There was no association between CEFM use and infant mortality (neonatal and post-neonatal) in full-term or late-term births. The study results do not support universal use of CEFM in pregnancies that are low-risk and at term.

ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth

Obstetrician-gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated or proscribed. Obstetrician-gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

758: Marked variability-cause for concern?

Continuous electronic fetal monitoring (EFM) is widely used to assess intrapartum fetal well-being during labor. However, little guidance is available regarding the frequency and interpretation of marked variability. We investigated the incidence of marked variability before delivery and its association with neonatal morbidity. This is a secondary analysis of a prospective cohort of 8,580 singleton deliveries from 2010-2015 at 37 weeks or beyond. EFM patterns during the 120 minutes prior to delivery were interpreted in 10-minute epochs. The primary outcomes were 1) a composite neonatal morbidity (death, respiratory distress, mechanical ventilation, suspected sepsis, meconium aspiration syndrome, therapeutic hypothermia, hypoxic-ischemic encephalopathy, & seizure) and 2) a composite adverse acid-base status (umbilical artery acidemia pH<7.10, elevated lactate ≥4 mmol/L, elevated base excess < -12). Outcomes were compared between women with and without marked variability defined as fluctuations in EFM amplitude of greater than 25 beats per minute ever in last 120 minutes. Adjusted risk ratios were estimated using multivariable logistic regression. Of the 8,580 women, 390 (4.5%) had marked variability before delivery. 757 (8.8%) of neonates had composite neonatal morbidity and 2,212 (26%) had composite adverse acid-base status. After adjusting for maternal age & obesity, women who had marked variability did not have increased risk of the composite neonatal morbidity 11% vs 8.7% aRR, [95% CI] 1.22 [0.91 1.63], though there was an increase in the risk of respiratory distress 7.2% vs 3.7% 1.85 [1.25, 2.70]. In contrast, there was an increased risk of composite adverse acid-base status 41.5% vs 25% 1.66 [1.47, 1.88]. This finding was driven by an increased risk of elevated lactate 42% vs 25% 1.66 [1.47, 1.88]. Marked variability occurred rarely before delivery and was not associated with increased risk of composite neonatal morbidity. However, marked variability was significantly associated with an increased risk of respiratory distress and elevated cord blood lactate.

Factors promoting or inhibiting normal birth

BackgroundIn response to rising rates of medical intervention in birth, there has been increased international interest in promoting normal birth (without induction of labour, epidural/spinal/general anaesthesia, episiotomy, forceps/vacuum, or caesarean section). However, there is limited evidence for how best to achieve increased rates of normal birth. In this study we examined the role of modifiable and non-modifiable factors in experiencing a normal birth using retrospective, self-reported data.MethodsWomen who gave birth over a four-month period in Queensland, Australia, were invited to complete a questionnaire about their preferences for and experiences of pregnancy, labour, birth, and postnatal care. Responses (N = 5840) were analysed using multiple logistic regression models to identify associations with four aspects of normal birth: onset of labour, use of anaesthesia, mode of birth, and use of episiotomy. The probability of normal birth was then estimated by combining these models.ResultsOverall, 28.7% of women experienced a normal birth. Probability of a normal birth was reduced for women who were primiparous, had a history of caesarean, had a multiple pregnancy, were older, had a more advanced gestational age, experienced pregnancy-related health conditions (gestational diabetes, low-lying placenta, high blood pressure), had continuous electronic fetal monitoring during labour, and knew only some of their care providers for labour and birth. Women had a higher probability of normal birth if they lived outside major metropolitan areas, did not receive private obstetric care, had freedom of movement throughout labour, received continuity of care in labour and birth, did not have an augmented labour, or gave birth in a non-supine position.ConclusionsOur findings highlight several relevant modifiable factors including mobility, monitoring, and care provision during labour and birth, for increasing normal birth opportunity. An important step forward in promoting normal birth is increasing awareness of such relationships through patient involvement in informed decision-making and implementation of this evidence in care guidelines.

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

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.

Continuous Electronic Fetal Monitoring during Labor: A Critique and a Reply to Contemporary Proponents.

A half century after continuous electronic fetal monitoring (EFM) became the omnipresent standard of care for the vast majority of labors in the developed countries, and the cornerstone for cerebral palsy litigation, EFM advocates still do not have any scientific evidence justifying EFM use in most labors or courtrooms. Yet, these EFM proponents continue rationalizing the procedure with a rhetorical fog of meaningless words, misleading statistics, archaic concepts, and a complete disregard for medical ethics. This article illustrates the current state of affairs by providing an evidence-based review penetrating the rhetorical fog of a prototypical EFM advocate.

Is continuous electronic fetal monitoring useful for all women in labour?

Routine monitoring of all women would prevent much neonatal morbidity, argue Edward Mullins and Christoph Lees, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary...