Fetal Heart Rate Monitoring

TEST LEADS TO NEEDLESS C-SECTIONS

I came across this article in June.  I read it.  I re-read it.  And re-read it again.  This is what I found most chilling: "No test is perfect. But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry."

I have been exceptionally lucky in my (still somewhat new) career as a doula.  Only a handful of times have my client's had "bad strips".  But the last two births I attended caused me to finally write about this.

Client A was planning a home birth with an obstetrician and a midwife.  She labored throughout the night and finally began pushing around 5:30 in the morning.  The midwife, working as the obstetrician's assistant, hand-held a doppler to my client's abdomen every few contractions and occasionally in between contractions.  As the baby progressed through the birth canal, I could hear his heart rate slow.  I was exhausted, having only had three hours of sleep in the previous thirty-six hours and I couldn't remember if we were supposed to listen for six seconds and multiply by ten or ten seconds and multiply by six.  Luckily as the doula, it was not my job and I continued to assist my client with her concentration and pushing.  Regardless, I was hearing a heart-rate at a bit under one hundred beats per minute. 

As the baby began to crown, the doctor instructed my client to reach down and pull out her baby.  He said something like, "Reach down and pull out your baby.  He may be a little floppy, but he'll be okay".  Client A reached down as her son turned, slipped her hands under his little armpits, he opened his eyes and gave out a cry.  He was not yet out past his belly, yet he was most definitely NOT floppy.  He was pink, breathing and crying.  His APGARS were 9 and 10.

22 hours later I was at the hospital, waiting for Client B to deliver her baby.  I wasn't actually with Client B during her delivery.  When I arrived at the hospital, Client B was being rushed off to the OR.  She had arrived at the hospital at 8-9 cm dilated, but the baby's heart rate was very low.  He was having huge decelerations during contractions.  In between contractions, which were coming every couple of minutes, his heart rate would recover somewhat, but never above 110 beats per minute.  During contractions it would plummet to around 60 beats per minute.  My client's doctor rushed her off to the OR with the intent of trying a vaginal delivery, but told her an emergency cesarean may be necessary.

Luckily, Client B was able to deliver vaginally.  Out came a pink, breathing baby that cried just a few seconds after being born.  Client B, her husband and new son joined me back in the labor and delivery room less than 20 minutes after the birth.

All of this caused me to wonder... I could HEAR these babies heart rates myself.  They WERE low.  No one was making it up, no one was misinterpreting the low heart rates.  But BOTH of these little boys were born perfectly healthy.  Neither one needed to be resuscitated, neither one was floppy, neither one was blue.  So what do low heart rates mean?

The American Academy of Family Physicians says, "The major risk associated with electronic fetal heart rate monitoring is a false-positive test that may result in unnecessary surgical intervention."

They also say, "The most important risk of EFM is its tendency to produce false-positive results. Unfortunately, precise information about the frequency of false-positive results is lacking, and this lack is due in large part to the absence of accepted definitions of fetal distress."

The American Congress of Obstetricians and Gynecologists says, "Although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions."

They also say, "The false-positive rate of EFM for predicting cerebral palsy is greater than 99%. This means that out of 1,000 fetuses with nonreassuring readings, only one or two will actually develop cerebral palsy."

WHAT????!!!  We're subjecting laboring women to a test with a 99% false positive rate that may result in unnecessary surgical intervention?

What exactly does false positive mean?  Merriam-Webster: : relating to or being an individual or a test result that is erroneously classified in a positive category (as of diagnosis) because of imperfect testing methods or procedures (emphasis mine).

It seems to me that in spite of all of the fancy medical technology, we may not know what a healthy heart rate for a baby is.  Could it be that we really don't know how long a baby can sustain a low heart rate?  Is it possible that what is dangerous for one baby may be perfectly healthy for another?  Is it possible that the machines we rely on to monitor our babies need to be calibrated?  I don't have the answers... but I know what I've seen and I know what isn't working.