What We Do Does Not Matter. Anymore.The new position of the American College of Obstetricians and Gynecologists on Electronic Fetal Monitoring
In 2009, approximately 3.9 million fetuses were assessed with electronic fetal monitoring (EFM). EFM is, by far, the most common obstetric procedure in the United States. In fact, it is considered the standard of care to utilize EFM for the assessment of fetal heart rate patterns and uterine activity during labor.
Hospitals in the United States spend millions of dollars annually to purchase the latest technology in EFM equipment and to train their nurses on the use of EFM’s. The reason so much time and money is spent on EFM equipment and training on its use is because it is currently the most reliable and sensitive screening tool available for damaging intrauterine fetal asphyxia.
In July 2009, the American College of Obstetricians and Gynecologists (ACOG) came out with ACOG Practice Bulletin No. 106 entitled: Intrapartum Fetal Heat Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Instead of providing guidance and clarifying the issues relative to EFM interpretation and management, ACOG only further muddied the waters on one of the most important procedures in obstetrics. All one has to do is look back in time to the first pronouncement by ACOG on EFM guidelines in 1975 and follow their ongoing emasculation of EFM interpretation and management principles to see how they have rendered this important screening device almost meaningless.
In June 1975 ACOG issued its first set of guidelines for EFM contained in Technical Bulletin Number 32 entitled “Fetal Heart Rate Monitoring”. With respect to intrapartum evaluation, ACOG stated as follow:
“The intrapartum period, with repeated stresses secondary to uterine contractions, poses a potential threat to every fetus. Fortunately, fetal tolerance or reserve is usually adequate to withstand the rigors of labor and the fetus emerges from its intrauterine state apparently unscathed. However, the exceptions of intrapartum death and depressed or damaged newborns are not infrequent. Fetal monitoring is now commonly used to identify and hopefully prevent these undesirable outcomes.
The clinical management of labor is frequently guided or altered by the observations of fetal heart rate and uterine activity data. The evoked fetal response in terms of FHR to the stresses of labor is the fundamental principle on which current understanding and management is based. Abnormal FHR observations, i.e. patterns, smoothness, can be associated with fetal acidosis and neonatal depression. Fortunately, when abnormal fetal responses are encountered, therapeutic steps can usually be taken to correct the problem.”
Technical Bulletin number 32 did not ignore the purpose for which EFM was intended; that is to make management decisions based on the evoked fetal responses to the stresses of labor as observed on the EFM strip and intervention to prevent fetal death, neonatal depression and fetal damage.
In September 1989, ACOG replaced Technical Bulletin number 32 with number 132 which was simply entitled, “Intrapartum Fetal Heart Rate Monitoring”. Recognizing that intervention is the key to prevention, ACOG acknowledged that: “The goal of intrapartum fetal heart rate monitoring is the detection of signs that warn of potential adverse events in time to permit intervention.” Specific FHR patterns associated with fetal compromise were discussed as well as interventions to alleviate those patterns. However, ACOG did acknowledge that if such measures were not effective, “preparations should be made for prompt delivery by the most expeditious route…” Again, ACOG acknowledged that EFM allows the clinician to assess the fetal state relative to hypoxia and acidosis and make management decisions in time to prevent the known adverse outcomes associated with fetal hypoxia and acidosis.
In July 1995 ACOG replaced Technical Bulletin number 132 with number 207 which was entitled: “Fetal Heart Rate Patterns: Monitoring, Interpretation, and Management”. Again, ACOG continued to recognize the association between intervention and prevention. In that regard Technical Bulletin number 207 states: “Intrapartum fetal heart rate (FHR) monitoring can help the physician identify and interpret changes if FHR patterns that may be associated with such fetal conditions as hypoxia, umbilical cord compression, tachycardia, and acidosis.” ACOG recognized that the ability to interpret FHR patterns and understand their correlation to fetal conditions allows the clinician to institute management techniques including prompt delivery by the most expeditious route.
Up to this point, ACOG gave credence to the physiologic basis for EFM by recognizing that alterations in the fetoplacental unit resulting from labor or intrapartum complications can subject the fetus to decreased oxygenation, leading to potential damage to any organ system or even fetal death. The scientific basis upon which the EFM was developed was to allow the clinician to answer the following question: “At the present time what is the condition of the fetus?” That is the most relevant question for any one making management decisions based on the data provided by the EFM.
There is an old saying that goes something like this: If you get them to ask the wrong questions, you don’t have to worry about the answers. ACOG adopted that philosophy in 2005 with Practice Bulletin Number 62 entitled “Intrapartum Fetal Heart Rate Monitoring” which replaced Technical Bulletin Number 207 from 1995.
ACOG simply changed the focus of their inquiry from helping pregnant women and their unborn babies to protecting their members from lawsuits. ACOG is no longer asking how to most effectively use EFM to help prevent adverse outcomes associated with fetal hypoxia and asphyxia. Instead, the question asked in Practice Bulletin Number 62 is: How good is EFM in predicting the outcome of cerebral palsy?
In response to the irrelevant question, ACOG responded as follows: “There is an unrealistic expectation that a non reassuring FHR tracing is predictive of cerebral palsy. The positive predictive value of a non reassuring pattern to predict cerebral palsy among singleton newborns….is 0.14%, meaning that out of 1,000 fetuses with a non reassuring FHR pattern, only one or two will develop cerebral palsy.”
This statement and the conclusions and recommendations in Practice Bulletin 62 constitute a collection of red herons. It was never the intention EFM to predict the occurrence of cerebral palsy. It was designed to prevent it. But ACOG asked the wrong questions and gave self-serving answers.
In July 2009, ACOG dramatically changed the rules that apply to EFM. ACOG took license from the NICHD (National Institute of Child Health and Human Development) Workshop Report on Electronic Fetal Monitoring. Over the course of two only, days the “experts” that made up the workshop decided to abandon the nomenclature for EFM that has been universally recognized and taught to obstetricians and nurses for decades. Today, EFM patterns are described as “Category I, Category II or Category III”. These terms were chosen out of the “significant concerns” for the “medical-legal implications” they would have for obstetricians.
The new ACOG guidelines for EFM have been widely criticized by obstetricians and labor and delivery nurses as being dangerously over broad and ambiguous. No longer does ACOG recommend preparations for prompt delivery by the most expeditious means when the FHR pattern suggests the potential for fetal compromise. Instead, the new ACOG guidelines recommend that clinicians watch ominous FRH patterns and wait until there is the need for emergent cesarean section in order to rescue the fetus from damage or death.
The new guidelines put mothers and their unborn babies at unnecessary risk. There is solid scientific evidence that certain FHR patterns are associated with significant fetal academia. The new guidelines allow obstetricians and labor and delivery nurses to not only push fetuses to the edge of the cliff, but allow them to push them off the cliff and hope that someone catches them before they hit the ground. There can be little doubt the babies will be harmed by the EFM guidelines adopted by ACOG. When that happens, hopefully, someone will take them to task.
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