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

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5423 (Published 05 December 2017) Cite this as: BMJ 2017;359:j5423

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

As we approach the third decade of the 21st century the debate goes on; to detect hypoxia in labour, should a baby’s well-being still be monitored with a monoaural stethoscope designed in the 19th century, measuring one variable, the heart rate, for 4 minutes in every hour? The evidence suggests it should if the pregnancy is classed as low risk (1). Evidence from the late 20th century showed that using Intermittent Auscultation (IA) in labour, there was no difference in the rate of asphyxia, and caesarean section rates were lower, compared to continuous Electronic Fetal Monitoring (cEFM). This evidence has justified the continued use of IA in low risk patients (1). This strategy reduces the risk of avoidable harm and unnecessary intervention in a physiological process. Has this practice made birth safer?
Maternity services have never been safer (2). However, in 2016/2017 in the NHS, obstetrics had the third highest numbers of claims for compensation, behind orthopaedics and A&E. The value of compensation claims for obstetrics alone was equal to the value of claims for all the other specialities in the NHS combined (3). This might be expected as babies born with poor outcomes require lifelong care. However, in 2015 the Each Baby Counts programme, run by the Royal College of Obstetricians and Gynaecologists, found that 76% of term, normally formed babies that suffered intrapartum stillbirths, early neonatal deaths and severe brain injury would have had a different outcome with different care (4). The 2017 MBRRACE-UK Perinatal Confidential Enquiry Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death showed that in 80% of intrapartum stillbirths, different care might have prevented the death (5). A recent review of claims for cerebral palsy by NHS Resolution in 2017 concluded very little had changed in the last 20 to 25 years (3). The same mistakes were being made and lessons had not been learned as most cases were avoidable. An earlier review of maternity claims from 2000 to 2010 by the NHS Litigation Authority made the same observation (6). The Each Baby Counts review showed errors with risk assessment in pregnancy and labour was common. Finally, the 2015 Morecambe Bay Review showed mothers and babies were harmed because of a desire to reduce intervention and increase normal births (7). With these unjustifiable levels of avoidable harm, it is hard to justify IA on the grounds it reduces the risk of unnecessary harm. Much greater harm is caused now by too little intervention, applied too late.
The RCOG Each Baby Counts programme set an aspiration to ensure no normally formed baby at term suffers intra-partum stillbirth, early neonatal death or severe brain injury at birth. Is this feasible? The high chance of a safe birth outcome after a poor outcome in the previous birth shows we know how to make birth safe in the 21st century when we choose to. In a baby classed as high risk, safety is given top priority. The baby will be monitored with cEFM. The healthcare professionals looking after the baby will more likely detect hypoxia early using cEFM. This is despite the evidence that cEFM is poor at detecting hypoxia. cEFM is a screening tool, but used properly can help achieve a hypoxia-free birth. The NHS Resolution Cerebral Palsy review showed healthcare professionals made the same known predictable, avoidable and repeatable mistakes with CTG interpretation (3). To ensure the baby is born safely, all the carers must do is avoid making those same predictable and avoidable mistakes. The primary aim of care in labour is to achieve a hypoxia-free birth which is possible in the 21st century.
Some would defend maintaining the status quo until there is new evidence that changing current practice would make birth safer (1). Unfortunately, the current evidence leaves out the views and expectations of the most critical group in any birth: the parents. Parents in the 21st century are better informed, expect a safe birth and have a much lower level of tolerance for things to go wrong. They are less likely to accept poor outcomes without question or without accountability. The recent seismic changes in the safety agenda in obstetrics in the United Kingdom has largely been driven by parents whose babies have suffered avoidable harm (8). In 2018, the days when healthcare professionals can hide behind evidence, bureaucratic systems and the law to avoid transparency or accountability and rationalise avoidable harm are numbered. The stories on the Each Baby Counts website show why we cannot go on causing avoidable harm in birth (9). Joshua’s Story by James Titcombe (10) is essential reading for evidence of the human cost of losing a baby from avoidable harm and the systemic obstacles parents face in search of the truth. With a system that causes up to 80% avoidable and predictable harm during birth, doing more of the same is clinically, ethically and morally indefensible.
So, should low risk mothers be monitored with cEFM? When discussing labour, do carers inform mothers a reliable accurate risk assessment cannot be guaranteed? Or that their baby will be monitored for one minute every 15 minutes? Or that antenatal fetal risk assessment is based on symphysio-fundal height measurement which is no better than abdominal palpation. Symphysio-fundal height measurement has a low sensitivity for detecting fetal growth restriction, a major predictor of poor fetal outcome (11). This means some high risk babies will be not be monitored with cEFM when they should, possibly resulting in a poor birth outcome. With such uncertainty and variation in care, should the choice of fetal monitoring still be made just by healthcare professionals? In the age of personalised care, mothers’ autonomy and choice, should we not ask mothers after an unbiased discussion, irrespective of their risk status, how they would like their babies monitored? If the mother chooses to have her baby monitored with cEFM, and her carers competently utilise cEFM avoiding predictable and avoidable errors, she can be reassured of the best outcome for her baby: a baby born without hypoxia. In the 21st century, is there any excuse to monitor any baby any other way?

1. Is continuous electronic fetal monitoring useful for all women in labour? BMJ 2017;359:j5423
2. Saving Babies’ Lives: A care bundle for reducing stillbirth, NHS England 2016.
3. Five years of cerebral palsy claims: A thematic review of NHSR data. M Magro 2017
4. Each Baby Counts 2015 Full Report. RCOG 2017.
5. MBRRACE-UK Perinatal Confidential Enquiry Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death 2017
6. Ten Years of Maternity Claims: An Analysis of NHS Litigation Authority Data. NHS Litigation Authority 2012
7. The Report of the Morecambe Bay Investigation March 2015. B Kirkup 2015.
8. Maternity Safety Strategy. House of Commons Hansard. Vol 632. 28 November 2017.
9. www.rcog.org.uk/en/guidelines-research-services/audit-quality-improvemen...
10. Joshua’s Story - Uncovering the Morecambe Bay NHS Scandal. James Titcombe 2015.
11. The Investigation and Management of the Small–for–Gestational–Age Fetus. Green–top Guideline No. 31 2013

Competing interests: No competing interests

14 January 2018
Odiri Oteri
Consultant Obstetrician and Gynaecologist
Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY