In an article about electronic fetal monitoring for the Philadelphia Inquirer, Test leads to needless C-sections, maternal-fetal medicine specialist Alex Friedman tells the story of an eclamptic patient:
My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.Between those opening and closing paragraphs, Dr. Friedman discusses the strange history of electronic fetal monitoring. As a resident, he had strong faith in fetal monitoring's ability to detect a compromised baby.
So we gave medication to start labor, and the nurses placed a fetal heart monitor....
For three or four hours that night, I struggled with my patient's bad fetal heart strip. I wanted her to avoid a cesarean section. She had type 1 diabetes, and I expected her sugars to swing wildly after surgery, and her recovery to be slow.
To improve the strip, the nurses and I tried giving her oxygen, changing her position in the bed, even rubbing the baby's head through the cervix to wake it up.
Finally, at 3 a.m., I felt compelled to recommend cesarean. The strip continued to look bad, and my patient's labor progressed slowly.
We went to the operating room, and delivered the baby by cesarean. My patient's child greeted the world pink and well-oxygenated.
The test was wrong again.
I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips....For the worst readings, we believed every second counted and rushed the surgery: If the baby wasn't delivered one minute from the first incision into the skin, we had moved too slowly.... But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry.The rest of his article discusses the ins (few indeed) and outs (many, and increasingly well-documented) of electronic fetal monitoring, which Dr. Friedman calls "an appallingly poor test." Towards the end, he discusses why obstetricians still use EFM when the evidence is strongly weighted against it [emphasis mine]:
Were we saving lives and averting disaster? Or were we performing unnecessary surgery?
Why do doctors cling to continuous fetal heart monitoring? An obstetrician will most likely point to the fear of being sued, but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don't work and can cause harm. "It's our bias that anything that can be quantified is an improvement," said H. Gilbert Welch, a professor at Dartmouth Medical School whose research focuses on harm caused by screening and over-diagnosis. "I think we get in trouble when we start promising things to . . . well [patients]," Welch said in an interview. "It is not that hard to make them worse."