RE: Response to "It is surprising that we are still using Electronic Fetal Monitoring though there is no evidence of it's usefulness"
References
1. Bassel H. Al Wattar, Emma Honess, Sarah Bunnewell, et al. Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis. CMAJ 2021;193:E468-E477.
2. Schifrin BS. Electronic Fetal Monitoring-Prevention or Rescue? Frontiers in pediatrics. 2020;8:503.
3. Spong CY. Electronic fetal heart rate monitoring: another look. Obstet Gynecol. 2008;112(3):506-7.
In responding to a recent article on electronic fetal monitoring (EFM) that extolled the benefits of intermittent auscultation (IA) for the assessment of the fetal heart rate during labor and delivery. Dr. Natarajan, finds it “surprising” that we are still using EFM worldwide, despite the lack of evidence of improved fetal or maternal well-being but with abundant evidence that it increases the cesarean section rate.
The merits and flaws of the published meta-analysis aside, Dr Najarian surmises from discussions with practicing Obstetricians that the reasons for EFM’s persistence around the world are 1) Fear of litigation, 2) There is no better alternative, and 3) Old habits die hard He chides practitioners because “no one has the courage to stop using it.” He then exhorts Canada to set the trend by ceasing to use EFM, arguing this action will “certainly” help many women, babies and the health care system.
We certainly agree that there is fear of litigation, but will this disappear if EFM is abandoned? (2) We doubt it. We also agree that there is no better alternative to fetal surveillance than EFM, the patterns of which are clearly related to the risk of acidosis and adverse outcome. (3) It is the classification of fetal heart rate patterns and management based on the presumption of acidosis that is deficient, but indeed, these are “old habits” difficult to abandon. Unlike EFM, there is no literature to support the notion that intermittent auscultation by itself is a sensitive or specific technique for the timely detection of actionable abnormalities in the fetal heart rate pattern, identification of early acidosis, assessment of uterine activity or clues to excess fetal head compression.
Failing that reconceptualization of fetal heart rate patterns, we reluctantly write in support of Dr. Natrarajan’s recommendation to eliminate use of EFM with the understanding that the technique will be abandoned completely for both antepartum and intrapartum testing with no recourse to it even if abnormalities are detected on auscultation. It would provide copious and important outcome data and medico-legal data that could be compared to those from a comparable control nation that continued to use EFM.
Thus, we believe, that the abandonment of EFM may be the only means of convincingly proving its value.