Wednesday, May 05, 2010

Test leads to needless c-sections

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.

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.
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.
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.

Were we saving lives and averting disaster? Or were we performing unnecessary surgery?
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]:
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."


  1. Not defending monitoring per se, but in this case wouldn't we prefer Type I errors (false positives resulting in unnecessary c-section) over Type II (false negative - necessary c-section, but don't)?

  2. Certainly FHM results in needless c/s. The example given was a rather bad one though. An eclamptic patient, especially a diabetic eclamptic woman has several risk factors without the fetal monitoring. By and large continuous fetal monitoring is probably not needed, but in her example I think it probably was.

  3. Xiaoshan, but it's not that simple. Unnecessary surgery raises the mortality risks for both baby and mother. So a c/section done "just to be safe" also has a safety cost, and not a small one.

    One of the biggest problems we have now is that in the US, postpartum death and injury is not well-tracked; it's possible our mortality risks are worse (or better) than we know. All of which makes weighing risk harder.

    Plus, absent EFM, the doctor would still be monitoring the woman, only intermittently and possibly using different methods.

  4. I like how they're surprised the test doesn't work-how could it possibly work when no proper trials were done in the early days of EFM to establish proper baselines?

    How can these proponents of medical SCIENCE keep being shocked by such an obvious oversight?

    And why is this news? We've known EFM is a shoddy test for a while now, what should be news is that it's still being used!

  5. One other thought I had was this:

    I think in the case of Melanie and I, fetal monitoring may have prevented an unnecessary cesearean - the doctors at the hospital were wanting to do a c-section after failure to progress after 10-12 hours of active labor. But because our baby's vitals were still showing fine from the monitoring - so our midwives were able to keep the doctors away, saying that there was no need for a c-section as the baby was doing just fine.

    Anyway, just a thought.

  6. You have to remember that we're talking about continuous electronic fetal monitoring versus intermittent hand-held monitoring, not cEFM versus no monitoring at all.

    So Xiaoshan, I'm guessing Melanie had cEFM once she had the Pit & epidural (because it is prudent to use that kind of monitoring with the increased risks of those medical technologies). But either way, hand-held auscultation could have also showed that the baby was doing fine, and I'm guessing that's the form your midwives used for much of the labor until Melanie chose to use Pitocin.

    There is a very well-documented increase in cesarean rates (which numerous health implications for mother and baby, both long- and short-term) with no increase in benefit to the baby using cEFM versus hand-held monitoring. That's what this physician is discussing. Does that make sense?

  7. Just my experience...

    I had an epidural so was continuously monitored during my labor. During several points while I was pushing my daughter's heart rate was recorded as dropping to about 95 bpm, which caused the midwife to become concerned and she paged a doctor. It was frustrating to me because I intuited everything was fine and really wondered how accurate the monitoring was. While I was pushing the monitor seemed to be moving around on my stomach and it seemed to me that it wouldn't be getting an accurate reading. I don't have any medical training, but had read enough during my pregnancy to know that this type of monitoring was frequently unnecessary and inaccurate. My daughter was born totally healthy with a 9 on her 1 minute apgar, fortunately with no further interventions.

    Hahahaha -- my verification word was "manger."

  8. scuppie, the same thing happened to me during the pushing stage. For my labour the nurses used intermittent hand-held monitoring, but the ob-gyn used cEFM for the pushing stage. According to the cEFM my baby's heart rate was dropping during pushing. I had been pushing for max 20 min, and was tearing a bit, but my doc cut an episiotomy to get the baby out on the next push. He had 9 apgar, so where was the fetal distress?

  9. At my first birth the EFM showed my daughter was distressed so she was cut out. My second birth, EFM showed my son was fine, but he was cut out because of previous c/sec possibly causing a rupture. He was actually dangerously distressed, apgars of 7 at 1min and 3, at 5. My third birth showed my son was fine, heart rate doing well. He was DEAD. he had died two days prior to his birth.

    At my fourth birth I stayed home.

  10. May I use the image of efm above? I am doing a project for school (power point) showing where use of Spice Gold (synthetic marijuana) can mimic s/s of ecmampsia and patient can be treated for the wrong thing.


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