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EDITORIALS: Ros Goddard Electronic fetal monitoring BMJ 2001; 322: 1436-1437 [Full text]

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Routine intrapartum electronic fetal monitoring in low risk women

Gordon C S Smith   (17 June 2001)

prevent deaths not litigation!

Sara Wright   (19 June 2001)

A wonderful resource of natural childbirth educators

Susan Myers   (7 July 2001)

Routine intrapartum electronic fetal monitoring in low risk women 17 June 2001
Gordon C S Smith, Sub-specialist Trainee Maternal-Fetal Medicine The Queen Mother's Hospital, Yorkhill, Glasgow Send response to journal: Re: Routine intrapartum electronic fetal monitoring in low risk women	While Dr Goddard, in her editorial of June 15 [1], appeared to acknowledge the fact that trials of routine electronic fetal monitoring are underpowered, she did not appear to draw the logical conclusion. Using her figures for intrapartum stillbirth and cerebral palsy of intrapartum origin, a trial powered (80% power, alpha 5%, two-sided) to show a 50% decrease in intrapartum stillbirth would need to recruit approximately 83,500 women to each arm and a trial powered to detect a 50% decrease in cerebral palsy due to intra-partum causes would require approximately 670,000 women in each arm. The current meta-analysis has less than 19,000 cases in total [2]. The evidence is not, as she states, "strongly against the routine use of electronic fetal monitoring". The evidence simply does not exist and, given the numbers required, it probably never will. Routine electronic fetal monitoring halves the risk of neonatal seizures even when applied to a low risk population [2]. Statements to the effect that electronic fetal monitoring has not been shown to reduce the risk of intra-partum stillbirth and cerebral palsy have the same fundamental weaknesses as statements associated with some previous public health disasters, such as "there is no evidence to suggest that blood products can transmit HIV" or that "there is no evidence that BSE can be transmitted to humans". Falsely equating "absence of evidence" with "evidence of absence" does not have a glorious history and should be avoided. 1. Goddard R. Electronic fetal monitoring is not necessary for low risk labours. BMJ 2001;322:1436-1437. 2. Thaker SB, Stroup DF, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor (Cochrane Review). Cochrane Database Syst Rev 2001;2:CD000063.
prevent deaths not litigation! 19 June 2001
Sara Wright, mother to 5 children - 1 stillborn none Send response to journal: Re: prevent deaths not litigation!	Ros Goddard's article mentions three recent Confidential Enquiries into Stillbirths and Deaths in Infancy, which she says have consistently recognised inadequate interpretation of the cardiotocograph as a prime cause of adverse events and then goes on to say that 'To prevent litigation trusts should act on this recommendation and ensure that such training is available free for all relevant staff'. Hospital trusts should be providing the necessary training not to prevent litigation if they get it wrong but to ensure that no baby dies needlessly. Ros Goddard does not appear to understand the utter devestation to a family that occurs when 'inadequate interpretation' occurs and a much loved baby dies as a result. The majority of patients do not want financial compensation when something goes wrong. What we want is honesty..what went wrong and why, for mistakes to be admitted and assurances that preventative measures will be taken to ensure that it doesn't happen again to somebody else.
A wonderful resource of natural childbirth educators 7 July 2001
Susan Myers, Certifed Childbirth Educator NC, USA Send response to journal: Re: A wonderful resource of natural childbirth educators	Finally! This editorial article is a wonderful resource for natural childbirth educators that sums up the known research about the lack of evidence to support routine, continual EFM during labor. As a teacher of natural childbirth, I know from the research and from common sense that EFM does little for the majority of unmedicated, low- risk mothers except restrict their movement during labor and lead to more medication and intervention. It also has the unfortunate side-effect of leading those present during labor who are supposed to be supporting the mother to 'coach' the monitor instead. Bravo to the BMJ for recommending the elimination of continual EFM in favor of more hands-on, one-on-one care by a nurse, midwife or other medically trained person who can check for distress in normal labors of low-risk mothers using the much more comfortable and just as effective (based on the research cited in your editoral) method of ascultation. This method is already used routinely in the midwifery model of care. I am putting this article on my must-read list for all my students desiring natural birth. I can only hope that the ACOG here in the US takes a similar stand. Unfortunatly in the medical climate here in the states, I am afraid that such a low-tech and cheap, effective and natural way to monitor labors will not be quickly embraced over the higher-tech, more expensive, less-effective EFM.