Andrew Bisits: Intrapartum CTG monitoring in breech presentation

Andrew Bisits

Intrapartum CTG monitoring in breech presentation

North of England Breech Conference, Sheffield

Day 2

Andrew Bisits is the Director of Obstetrics at the Royal Hospital for Women, Sydney, Australia. His hospital sees over 4,000 births per year. Andrew is working on several initiatives to promote normal birth by establishing primary midwifery care for women and by attending vaginal breech births. He has also created a vaginal breech training course, Becoming a Breech Expert (BABE).

Today’s presentation examined the evidence for CTG monitoring in breech presentation. To what extent is there evidence? To what extent are doing it because it’s part of our comfort zone and what we’ve always done?

Andrew does not have firm answers, but finds this topic necessary and helpful to discuss. At this conference, people can think clearly and are invested in the issue. At home where he works, people are so busy and so fearful that they just react, they don’t think. Here at this conference, we’re sitting back and thinking, discussing, and trying to look at evidence in the broader context. There are so many pressures back at the workplace that you can’t think about these things.

He will ask two main questions about CTG monitoring:

• Do normal women with normal babies need it?
• Can CTG help make VBB as safe as cephalic vaginal birth?

There are small—perhaps significant—differences between cephalic and breech vaginal birth.

The question of CTG monitoring has to be viewed within the context of the various pressures on providers to intervene: We have this normal process, yet we continually feel pressure to intervene. Some of the pressure might come from evidence, but social pressures and a huge medico-legal industry exert the most pressure. Despite being in an evidence-based era, the pressure to intervene based on factors other than evidence—medico-legal cases, social pressures, various opinions—is huge and cannot be ignored.

Learning from adverse events:
What prompted Andrew to talk about this? He was party to a number of adverse events in New South Wales related to breech. By adverse events, he means neonatal mortality (NNM), perinatal mortality (PNM), or very severe asphyxia. He’s familiar with 8 serious adverse events over the past 2 years: 3 births had mechanical difficulties. 2 births had clearly abnormal CTGs (blindingly obvious ones, no dispute). But the 3 other births had CTG patterns where the outcome was unexpected. Again, glaringly unexpected.

How breech relates to shoulder dystocia:
25 years ago, the whole approach to shoulder dystocia was terribly primitive. Well-meaning providers would yank, shout, and scream. The baby might have a bad outcome and the staff would be traumatized. If you read textbooks from that time, one instruction was to apply firm traction on the head. That’s been reversed because even though the evidence is not watertight, we’ve systematized the whole approach to shoulder dystocia, and it’s made a difference. He no longer hears about people shouting and screaming. Rather, today it’s very quick and focused: We got the woman into McRoberts, we did this, we did that, we did the next thing, and the baby came out. The providers followed a series of steps clearly.

A similar thing is possible with breech for mechanical problems; we can make those births safer. Knowing the normal and the abnormal in detail allows us to prevent the majority of nasty mechanical problems in a breech birth. We have to keep thinking about it in a creative way, but it’s manageable.

The tricky question, however, is the issue of intrapartum monitoring and how the baby behaves as a breech vis-à-vis oxygenation. When a CTG is glaringly abnormal, there’s no argument. You do something. You act right away in cases of persistent bradycardia or persistent tachycardia. But most cases are in between these two extremes.

Making breech birth safer
There are 2 achievable goals in making breech birth safer: getting better at resolving mechanical difficulties and acting promptly in the case of clear CTG abnormalities. But that leaves us with the remaining breech births with bad outcomes in which the CTG monitoring does not indicate a problem.

The evidence for CTG
The next part of Andrew's presentation delved deeply into the literature on CTG monitoring. The evidence we rely on for fetal monitoring primarily comes from cephalic births. He referred to the 2017 Cochrane review, with regard to neonatal seizures. If you looking at high-risk subgroups, the effect of CTG on NN seizures is not as strong as with low-risk groups. That has an implication for breech birth. The nastiest outcomes we have are HIE, including perinatal death. If the effects more obvious in the low-risk group, that might argue for doing monitoring for breech births, even for low-risk breech births.

Whatever evidence we do have, it’s indirect. The critical point is that CTG monitoring halved NN seizures with no effect on mortality, no effect on longer-term cerebral palsy, but with an increase in cesarean/forceps deliveries. Andrew noted, though, that this short-term difference in NN seizures didn’t translate into longer term CP.

(Rixa's note: Andrew referred to an Irish study but I didn't catch the citation; perhaps it was the 1985 Dublin RCT of IP fetal heartrate monitoring?)

INFANT study
Next, Bisits discussed a recent study by Brocklehurst et al, the INFANT study (Lancet March 2017). It was a RCT of 46,000 women in the UK. All women had indications for FHR monitoring (traditional risk factors). They were randomized into two groups: CTG with or without computerized decision support. Preliminary evidence suggested that computerized decision support might lead to better outcomes by eliminating interobserver variation and thus more accurately indicate when intervention was needed. This was a very well-designed RCT. The trial groups had very similar demographics and a similar frequency of induction, epidural, cesarean, forceps, and spontaneous birth.

3 years ago, Brocklehurst said that if this study doesn’t show a difference in outcomes, it would really raise questions about the overall value and future of CTG itself.

Andrew noted that big money was fueling this study. He didn’t say this maliciously—but 7% of the NHS budget goes towards settling claims in cases that involve CTG. 7% of the NHS budget! No wonder there’s an incentive to get the best out of CTG and find ways to minimize these huge payout cases.

The study itself found no difference in outcomes between the two methods of CTG interpretation--this despite big hopes for this new computerized technology. The researchers followed the babies for 2 years after birth: still no differences. Andrew noted that some of the authors dropped out of the study because of the findings.

We’re in an ongoing quagmire regarding CTG in general. And it’s a very messy quagmire. Andrew noted that CTG monitoring is “welded into the fabric of maternity care” because of medico-legal pressures, rather than because it’s effective. Yes, it does have a marginal effect, but it’s not as much as it’s made out to be.

When he talks to solicitors about CTG, they tell him, “What we believe is the CTG. What we hear from the doctors, that’s all subjective. But when we see something on paper, that’s something we can all agree on.” Despite all of its limitations, we are stuck with CTG.

The major conclusion of the INFANT study was that we have to look at other ways of monitoring fetal oxygenation during labor. CTG has significant limitations in being able to reduce major hypoxic damage to babies.

What are the implications of the INFANT study for breech babies? It depends on how you interpret the study! Some people would conclude that you should be doing CTG, others would conclude you don’t need to.

Andrew next referred to a 2016 Finnish study on CTG in breech versus vertex delivery by Toivonen et al. The authors found that late decels and decreased variability were more common in breech labors compared to vertex labors. For example, late decels were seen in 13.9% of breech vs 2.8% of vertex deliveries, and decreased variability in 26.9% of breech vs 8.3% of vertex deliveries. Overall, the authors found that CTGs are different in breech labors compared to vertex; whether or not those differences are clinically useful is still in question.

Shawn Walker: Yes, I also felt that this study was interesting but not strongly useful for clinical outcomes.

Jane Evans: Why? Do more breech babies have shorter cords so they are pulled more? We need to figure out why. These are all the things that would affect that. Can we measure the stress levels of women who aren’t on CTG vs who are (via a swab)?

Andrew Bisits: Yes, you could do that. There are a number of theories about the cording of breech presentations.

ST-waveform analysis
The next study of interest was a 2014 study by Kessler, Moster, and Albrechtsen titled Waveform analysis in breech presentation (BJOG). The authors took a series of 433 breeches and 5577 vertex babies who were monitored with ST-waveform analysis (a form of fetal ECG, different than traditional electronic monitoring). In theory ST-waveform analysis provides a better assessment of cardiac oxygenation.

Has it proven to be so? Overall there’s no glaring benefit to ST-waveform analysis. There are some enthusiasts, but if you look at the hard evidence, there are no huge standout figures. The vertex group was a higher risk group overall compared to the breech group. See the following slide for details:

There were 3 breech babies with significant problems. See the following slide for details.

In the one case of fetal death, the ST monitoring didn’t suggest an abnormality, nor was it a difficult birth. Maybe there was something wrong with baby? In this case, the CTG provided a falsely reassuring result.

There were also 2 cases of moderate HIE. One was quite severe with nasty seizures. But it wasn’t picked up in the monitoring, nor was it a difficult birth. In the other case of HIE, there was some suspicion due to the CTG tracings.

Overall, 2 of the 3 bad outcomes were not picked up by fetal monitoring. This means CTG/ST has a falsely reassuring rate of 2/500. This compares with the rate of severe outcomes with cephalic high-risk births (2/500). Would this have been higher in the breech group without monitoring? This is the question that is tough to answer.

Main conclusions (from a dearth of evidence): 
There are no clear answers about CTG monitoring for breech babies. It’s hard not to recommend monitoring; the social, institutional, and medico-legal pressures are too great. It’s too welded into the fabric of our care. Andrew doesn’t like saying that, but he thinks it’s the reality.

We need to be clear with women about the effectiveness of monitoring, and then a decision can be made whether or not it is done. We also need to look for other methods of monitoring the baby’s oxygenation during labor. Perhaps we should consider the use of buttock lactate/ph. In the 80s, these came up with a lower than normal pH for breech babies. RCOG guidelines said it’s not recommended.

~~~~

Q from Julia Bodle: I’m thinking back to what CTG does and doesn’t do—halving the rate of NN seizures. What are the long-term outcomes for the babies who have NN seizures?

Andrew Bisits: There are 2 differing views on this.
1) In the follow-up from Dublin CTG trial, they could not detect an excess of CP.
2) If you read the Cochrane review and the comments that they invite after it, a Swedish researcher quotes a Swedish study that looks at grade-2 HIE and its longer-term implications. From this particular Swedish study, there is a 48% incidence of CP. Further, 18% of babies had some significant cognitive issue (not sure at what age). Only 25% were actually normal at age 15. NN seizures are not benign in the long-term, according to that Swedish study. I always believed in that Dublin data, so I’d need to look up the original study the Swedish researcher citing.

Andrea Galimberti: In the UK we tend to prefer intermittent monitoring when possible because women can move around. What is the difference between high-risk women monitored and the low-risk women who have intermittent?

Andrew Bisits: From a biological point, nothing! From a psychological standpoint, lots.

Q from audience member: What about other outcomes besides CP, such as ADHD, autism, etc. Have you read anything about this?

Andrew Bisits: There is a weak link with ADHD. The slightly concerning one is cognitive impairments noted at age 15-17. They’re the ones that have been reported in Sweden.

Q from audience member: Might it have more to do with NN management and cooling?

Andrew Bisits: We haven’t changed the instance of CP despite all these advances; it’s still 1/1000.

Q from audience member: There’s no good evidence that any monitoring improves the outcomes because nobody’s done the studies. Certain CFM has known harmful effects. We may be doing a lot of harm while trying to reduce these small things.

Andrew Bisits: In the cold light of day, I would agree with you. The problem is we’ve got this whole mindset that is welded—not by a thread—into the whole fabric of maternity care at all levels.

Q from audience member: Don’t we have to make sure we do no harm, first?

Andrew Bisits: We would hope, yes.

Betty-Anne Daviss: As a practitioner, we have to be very careful in Canada and stay very close to the SOGC guidelines not to raise the ire of the OBs in our unit. I think we have to start understanding what the normal breech is with some of our other parameters. I’m concerned that we’re making the decision about what a normal Apgar is for a breech baby, because Apgars are different for breeches. We have to normalize a low pH for breech babies. We have to put those together with the monitoring. We should start to write down things like floppy/not floppy that seem to raise our concern. As researchers, we need to start putting those things together for what the norm is for breech.

Emilano Chavira: There’s such an obvious parallel between pros/cons of CFM and the breech birth itself. For example, the presentation by Lawrence Impey focusing on all the outcomes of NN survival vs death, and acknowledging that it’s just one outcome and there are so many others we can look at. Your presentation looked at NN seizures/death…but what about everything else—maternal procedures, cesarean sections—that comes with monitoring? I’m very sympathetic about both the audience’s questions and with your presentation. Is there any option at all? Can we engage in informed consent for these things? What approach does the mother want to take? Maybe informed consent is a first step towards dislodging this “welding” that we have.

Andrew Bisits: Yes.

Julia Bodle: This INFANT study affirms my belief that the world is a much more corrupt place than I had thought it was. I just saw a press release from the company that makes the K2 Guardian CTG technology, the one used in the study, claiming that it reduces stillbirth and brain damage! K2 medical systems is sending these press releases out, clearly misrepresenting the evidence from the INFANT study. In fact, the RCOG and BFMFS just sent a joint statement warning people about this press release. I just got the notice yesterday in my email. It’s outrageous! On the upside, you can use this study in court in your defense; the type of monitoring doesn’t make any difference.

(Rixa's note: I can not find the RCOG/BMFMS statement online, but I did find this news release mentioning it. K2 Medical systems is making those claims by comparing the outcomes of the INFANT study with the outcomes of the BirthPlace study.)

Andrew Bisits: Do any units do intermittent rather than routine CTG for breech?

Julia Bodle: The current policy is to talk to the women, give them evidence, and then they choose. Our unit has a policy that it’s recommended.

Andrea Galimberti: We are discussing modifying the policy. And of course women can choose.

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Lamaze/ICEA Conference part 2

Saturday did not start well for me. I slept maybe 2 hours the night before, due to a combination of congestion and two little children who decided to wake up and either cry (Zari) or party (Dio) most of the night. I wondered how I would make it through the day...

But I didn't have much choice. My presentation--based on my article Attitudes Towards Home Birth in the US (PDF)--was in the morning. I arrived early and ran through my presentation to make sure I wouldn't go over time. I used prezi rather than PowerPoint, as I think it's a much more dynamic and visually interesting platform.

Safe or Selfish? Attitudes about home birth in the US on Prezi

I had a fun time giving the presentation. We had lots of discussion and comments both during and after my talk. Even though I was dead tired, I didn't feel it while I was speaking. We had to cut the discussion short to make it to the big celebratory luncheon. I sat with April, a lovely CPM from Dayton, Ohio, who works closely with Dr. Guy of Miami Valley Hospital in Dayton and Dr. Can't-Remember-His-Name in Cincinnati. These OBs are known for supporting women who want VBACs, vaginal breech births, vaginal twins & triplets, etc. She and I talked about her training (master's level degree from the Midwives College of Utah) and her reservations about the loopholes in the CPM certification process.

Later in the day, I found out that Geradine Simkins, president of MANA, and Dr. Raymond De Vries were both in my audience! I had never met them face-to-face before and so didn't know who they were at the time. I talked with Geradine afterwards for a while. She urged me to consider doing research with the home birth statistics MANA has been compiling over the past decade or so. She was especially curious about my suggestion that NARM upgrade the CPM certification into a 4-year university degree. We weren't able to talk much because of our busy schedules, so I'll have to continue our conversation via email or phone.

I did double duty in the afternoon breakout sessions. First, I listened to Christine Morton's presentation about the historical evolution of doulas and how the profession is intimately connected with the development of childbirth education. Really fascinating! I've "known" Christine online for a while--she's a sociologist at Stanford University and doula--but never saw her in person before the conference. I never had time to talk with her face-to-face, unfortunately. But here's a virtual wave hi, if you're reading!

I then ran to another session about MoreOB, an evidence-based program being adopted throughout Canada. The presenters were an obstetrician, Dr. Karen Bailey, and two nurses/childbirth educators, Liz DeMaere and Sharon Dalrymple. With MoreOB, what childbirth educators teach in the classroom is exactly what happens once the laboring woman arrives in the hospital. This is definitely not the case in most parts of the US, as attendees emphasized over and over again throughout the conference.

The speakers gave a case study about how MoreOB works in their hospital regarding fetal monitoring. The hospital staff has a clear set of guidelines for when to use intermittent auscultation (IA) and when to use continuous electronic fetal monitoring (cEFM). Basically, unless a woman has certain clearly-delineated risk factors, she will only be monitored with IA. If a nurse, midwife, or physician wants to use cEFM, they have to document which specific medical condition warrants using cEFM. If it does not meet the established criteria, they won't be allowed to use cEFM. And they'll receive a talking-to from the charge nurse!

I entered when Dr. Bailey was talking about the before and after experiences in her hospital. She works in a small rural hospital in High River, Alberta that cares for only low-risk laboring women. Before adopting MoreOB, every woman would automatically be hooked up to the fetal monitors and confined to bed. After MoreOB was put into place, no one goes on the monitors--no 20-minute admission strips, even--unless there's a very specific reason for it. At her hospital, that means almost everyone receives IA and is encouraged to stay out of bed. Dr. Bailey explained it like this: "I'm an old cowgirl. And every cowboy or cowgirl worth their salt knows that you can't just slip your feet into a good-fitting pair of cowboy boots. You have to wiggle and jump and shimmy your way into your boots!" (This said as she's hopping around the room on one foot demonstrating the gymnastics required to put on cowboy boots). She was adamant about keeping women walking and moving and out of bed. She joked about how they used to always know where to find the laboring women--in bed. But now, they never know where to find them. "Where's patient X? Not in her room? Not in the shower? Where could she be? Oh....probably the staircase!"

We then moved into three small groups, each tackling a common scenario in US hospitals: augmentation, induction, and restriction of food/drink. We were instructed to discuss how to implement evidence-based, consistent policies, similar to what their hospital has done, for these various scenarios. I joined the induction group, which Dr. Bailey was part of. Our group, I sensed, felt extremely hampered and frustrated with how little they felt they could do to change the rampant rates of both elective and quasi-medical inductions (i.e., for a "big baby" or being "overdue" at 40 weeks and 1 day). Where Dr. Bailey works, they only do elective inductions for really extreme circumstances--such as a grand multip with a history of 30-minute labors who lives two hours away from the hospital and a really big snowstorm is moving in (close to a direct quote from Dr. Bailey). They don't start offering inductions for post-dates until 41 weeks 3 days. So if a physician wants to book a patient for an induction, and the induction doesn't meet certain evidence-based criteria, the charge nurse will tell the doctor--and I quote Dr. Bailey--"Bullshit."

The last session on Saturday was a general session by Dr. Warren P. Newton. He teaches at the UNC School of Medicine and works with UNC's department of Family Medicine. He spoke about developing a systems approach to health care. While the quality of individual physician-patient (or midwife-client) interactions is key, we also need to ensure that everyone has equal access to such care. He explained the implementation of the Family Centered Medical Home into the UNC Family Medicine Center and demonstrated very impressive results: much less waiting time for appointments, better health outcomes, etc. I'm still fuzzy on what exactly a FCMH is and how it different from standard medical care systems, but it was very intriguing.

The last part of his presentation explained how he applies these approaches to maternal-child care. His staff includes family physicians, nurse-midwives, nurse practitioners, and acupuncturists. They have really impressive numbers with their maternity patients. They do about 350 births/year and have a primary cesarean rate twice as low as the overall primary c/s rate at UNC. Their practice's epidural rate is 25%, compared to 82% for the rest of the hospital's maternity patients. (He noted that not allowing the anesthesiologists into the woman's room soon after admission to "talk about her pain relief options" and "assess her airway in case she needs an emergency cesarean under general anesthesia" had a significant impact on lowering the epidural rate.) He's also been involved in backing up the only freestanding birth center currently in North Carolina, the Women's Birth and Wellness Center, which does about 400 births per year. He demonstrated a strong belief in the normality of the childbearing process and of women's inherent ability to give birth, especially when given the time and space to do so.

By time 5:15 pm rolled around, I was beat. I could hardly stand upright and was feeling quite unwell. I wanted to stay longer and talk, but I needed to get back to the kids, eat dinner, and go to bed. My sister and I split a Tylenol PM; the sleep aid is benadryl, so it was perfect for our congested noses. (Thanks to April for finding someone with medications on hand!) It did the trick, and I was able to have a good night's sleep (which meant I only woke up 3 times to pee, and Dio only woke up once at 2am.) My apologies to anyone who thought I seemed disinterested or distracted on Saturday...it was just the fatigue!

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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."

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We are the Borg

What happens when the BirthTrack meets the LaborPro?

Birthing women become the Borg.

Don't worry--some intrepid bloggers have deconstructed both of these menacing gadgets for you. Read my analysis of the BirthTrack: More! Better! BirthTrack! (TM). And Nursing Birth, a L&D nurse, just wrote about LaborPro: The WORST Idea Since Routine Continuous Fetal Monitoring for Low Risk Mothers.

Let's beat back the Borg invasion before it's too late! 

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More! Better! BirthTrack (TM)!

Remember in Pushed, where Jennifer Block mentioned a company developing a continuous dilation and station monitor that would clip onto the cervix? Well, the BirthTrack is here and being actively marketed to both doctors and mothers-to-be. It consists of an internal electrode that is screwed into the baby's head and two ultrasound clips that attach to the cervix. Its purported benefits include (quotes from the manufacturer's website in red):



It will reduce the number of vaginal exams during labor. Instead, you'll have two clips permanently attached to your cervix the whole time! Sign me up! "In the usual procedure vaginal examinations are performed numerous times during normal labor. In the case of labor arrest or other complications the number of vaginal examinations increases."

It will help doctors perform a cesarean for "failure to progress" even faster! Because we're not jumping the gun fast enough as it is, with our 31.1% cesarean rate! Remember, labor must never stop or slow down! "In the event of non-progressive labor, the diagnosis may be delayed, thereby preventing the mother from obtaining the best medical care."

It will make sure you don't go too slow or too fast! "In managing labor, obstetricians are faced with a number of important challenges, including...identification of inadequate progress of labor and assessment of a quick developing labor process."

It is more accurate! "The information available to the caregiver is inaccurate due to the objective nature of the measurement and intermittent [assessment]."

You'll have information streaming at you non-stop, every second! Next up: sending the info to your Blackberry in real-time! "You will have continuous information regarding the progress of labor and you will know the position of your baby every second."

Your partner will be more involved in the birth! He can stare even more at the machines and less at you! "Your partner will be able to be an active participant in the labor process as he/she follows the progress of the partogram on the screen next to your bed."

Oh and of course, as this last statement indicated, you WILL be lying in bed!
You won't even notice it! It will just "minimally disrupt patient comfort."

It's more convenient for your doctor's pocketbook! He will get sued less, since the machine gives him "a lower risk of malpractice"! BirthTrack is also a "Support tool during litigation--BirthTrack provides full documentation of cervical dilatation and fetal head descent during the labor process."

More is better! This new device results in "significantly improved medical care"!

More is cheaper! By buying this expensive piece of machinery, we can achieve "reduced costs" by reducing human-to-human interaction even more! We can also make more money at each birth by increasing the cesarean rate due for failure to progress!

It provides not one, not two, not three, but FOUR paths to getting an infection. First, your water is broken. Next, an internal fetal monitor is screwed into your baby's head. Then you get two clips attached to the opening of your uterus. Free ride to any germs looking for some action!

My suggestion to BirthTrack and to those who stand to profit by making, marketing, and selling this new piece of gadgetry: get your hands (or rather your cervical clips) outta my vagina and outta my pocketbook!

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