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

BMJ 2017; 359 doi: (Published 05 December 2017) Cite this as: BMJ 2017;359:j5423

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

This is a very useful debate which I incorporated into my recent HealthWatch Autumn Newsletter article.

Mullins and Lees argue

"Furthermore, intrapartum monitoring would not be expected to reduce the incidence of cerebral palsy because, contrary to widespread belief, it is rarely linked to intrapartum events"

So why are we bothering to try to prevent cerebral palsy (CP) if it is rarely linked to intrapartum events ? This was not what the authors of the Each Baby Counts told us about the failure of the carers to read the CTG accurately. It certainly is a very convenient argument but if CTG monitoring reduces seizures why not CP ?

"Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician."

If the care of women's labour was transferred from the obstetrician to the midwife and the outcome was poor then the midwife would be blamed. But if the midwife transfers care to the obstetrician, it is still the midwife who is to be blamed !!!

"An important limitation of the study is that aggregated data of a large birth registry database were used and adjustment for confounders and clustering was not possible. However, the findings are unexpected and the obstetric care system of the Netherlands needs further evaluation."

If it suited the argument you could easily emphasise the role of the confounders !

I do not have any strong views on the CTG, although logically it should reduce poor outcomes. After 35 years of reading CTGs it is not that easy. But, as I state in the HealthWatch article, no matter how good and timely the action of the obstetrician the outcome will be strongly affected by the care the baby gets immediately after delivery and if the baby gets early cord clamping and as a result has severe hypovolaemia, most will die or get CP. So the obstetrician's good care is lost.

Peter Brocklehurst explains the CTG is a screening test. So what is the difference between a screening test and a diagnostic test ? It is all down to sensitivity and specificity. The CTG has not been found to be sensitive or specific enough for the outcomes of CP and death. But is this down to the subsequent care of early cord clamping ? Can Peter tell me what test in labour is diagnostic for outcome of CP or death ? I do not know of any !!!

Competing interests: No competing interests

06 December 2017
David J Hutchon
Retired Consultant Obstetrician
Darlington Memorial Hospital