The current standard for labor and delivery practices is to use electric fetal monitoring (EFM) to evaluate a baby’s status. Physicians and nurses will review the EFM readings in order to reduce the risks of a birth injury, such as erb’s palsy or cerebral palsy (CP), and death as a result of inadequate oxygen to the fetal brain. However, there is some concern regarding whether the EFM does more harm than good due to inconsistent interpretations of the EFM strips by both physicians and nurses.
EFM has been used in the labor and delivery setting since the early 1970s. Essentially the EFM monitors the fetal heart rate and reproduces the fetal heart tracings on both a screen and paper to enable the medical staff to determine when a baby is distressed. The readings are ultimately used to determine if the baby needs to be delivered surgically by Cesarean section or can be delivered vaginally.
However, unlike a basic medical marker like temperature or blood pressure which is not subject to interpretation, the EFM tracings can be interpreted differently by different doctors. Depending how the individual physician interprets a monitoring strip there can be a difference in opinion about the proper course of action. Recent information has show an increase in the number of c-section deliveries. For example, in Chicago almost 40 percent of deliveries are done via Cesarean.
Some critics say that this rise in c-section deliveries is the result of an increased fear among labor and delivery physicians of potential medical malpractice litigation. While a Cesarean is not necessarily a dangerous option, it still carries risks for both the mother and infant and is much more expensive than a simple vaginal delivery.
In an attempt to provide labor and delivery physicians with directions for interpreting EFM tracings, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) created guidelines regarding EFM interpretation.
While the former guidelines divided readings into “reassuring” and “non-reassuring” categories, the new guidelines separate the readings into three categories— Category I, II, and III. Category I means that the fetal heart rate is normal and no specific actions is required. Under Category II there is the potential that the baby is in distress so the physician is alerted to closely evaluate and survey the baby by reevaluating at the entire clinical picture and not just the EFM tracing. When classified as a Category III tracing the EFM is officially abnormal and requires the medical staff to immediately evaluate the infant’s condition and take steps to reverse the abnormal heart rate.
However, these new guidelines still leave much to be desired and are far from helpful in preventing birth injury malpractice. A c-section is an option when a baby needs to be rescued from fetal distress. The category system seems to be designed to screen doctors and nurses from medical malpractice exposure in settings where negligence on their part may have unnecessarily injured an unborn child or mother. For example, if a baby is born with CP the labor and delivery physician might argue that the EFM strips were interpretted as Category I so the medical staff assumed everything was fine and neglected to assess other clinical factors.
While EFM strips are important the category system suggests that there are instances where they can be evaluated without considering other medical factors, such as the mother’s blood pressure, the mother’s heart rate and temperature, what medicines the mother might have been taking, frequency of contractions, and how fast labor is progressing. In fact, it is because the EFM strips are subject to an individual physician’s interpretation that they cannot be neatly categorized and must be considered on an individual basis.