Continuous electronic fetal monitoring, or EFM, can have a negative impact on your birth experience. Adriana Lozada explains how. And what you can ask care providers for to alleviate the complications it can cause.
What is your experience with continuous electronic fetal monitoring while in labor? Tell us about your psychological and physiological response on Instagram @birthfulpodcast.
Related Birthful episodes:
- How to Avoid a Cascade of Interventions
- [Birth Stories] 5-Day Induction Makes for a Very Confusing and Grueling Birth
- How to Have a Great Hospital Birth
- Just Say “No” to Routine Continuous Fetal Monitoring, Childbirth U
- What fetal heart rate monitoring can – and can’t – tell us , from Robert Stewart, M.D.
- Fetal Heart Rate Monitoring During Labor, The American College Obstetricians and Gynecologists
- Interpretation of the Electronic Fetal Heart Rate During Labor, American Family Physician
- The Evidence on: Fetal Monitoring, Evidence Based Birth
- Fetal Monitoring: Creating a Culture of Safety With Informed Choice, The Journal of Perinatal Education
- Fetal Monitoring During Labor, University of Michigan Medicine
- External and Internal Heart Rate Monitoring of the Fetus, University of Rochester Medical Center
- Monitoring for Perinatal Safety: Electronic Fetal Monitoring, Agency for Healthcare Research and Quality
- Simulated Electronic Fetal Monitoring, University of Tennessee Research Foundation
- Continuous Electronic Fetal Monitoring (EFM), Lamaze
- A half century of electronic fetal monitoring and bioethics: silence speaks louder than words, Maternal Health, Neonatology, and Perinatology
- “Even today, EFM remains immune to the doctrine of informed consent despite continually mounting evidence which proves the procedure is nothing more than myth, illusion and junk science that subjects mothers and babies alike to increased risks of morbidity and mortality. And ethicists have remained utterly silent through a half century of EFM misuse.”
- Electronic fetal monitoring: does it really lead to better fetal outcomes? American Journal of Obstetrics & Gynecology
- The future of electronic fetal monitoring, Best Practice & Research Clinical Obstetrics & Gynaecology
- How to Read a Fetal Monitor During Labor, VeryWell Family
- Fetal Monitor, WHO
- Intrapartum fetal heart rate monitoring: Overview, UpToDate
- Electronic Fetal Heart Monitoring, MyHealth Alberta
- Fetal Monitoring, Sutter Health
Straight Talk about the Effects of Electronic Fetal Monitoring on You and Your Baby
Hello, mighty parents and parents to be. I’m Adriana Lozada and you are listening to Birthful, and today, just like every other week, I’m here on my own talking to you one on one about a topic that I want to dive deeper into. And today, I wanted to piggyback on our last conversation on how to have a wonderful hospital birth and talk about continuous electronic fetal monitoring, because that’s a procedure that can really impact your birth experience. In fact, for low-risk labors that happen spontaneously at term, routine, continuous electronic fetal monitoring, or continuous EFM for short, is in the opposite category of may help, can’t hurt. It actually does not make labor safer for low-risk births, and it does hurt by negatively impacting your experiencing and labor flow.
So, let’s start by defining what it is. EFM or cardiotocography is the monitoring of your baby’s heartbeat, which can be done externally or internally. And the most common method is the external monitoring, and they do that by using a machine with a sensor that is placed on your belly. That sensor is an ultrasound transducer and usually looks like a hockey puck. It’s connected to a machine that shows the rate and pattern of your baby’s heartbeat on a computer screen or on graph paper, and it is very common for the heartbeat to be monitored along with the uterine contractions. And to monitor your contractions, what they do is they use a similar hockey-puck-like device that’s placed on the top of the abdomen, and then both the baby’s heartbeat and the frequency of contractions get graphed side by side for easy comparison if needed.
Now, EFM was put into practice in the ‘70s and it quickly became widespread, even though there had been zero research or testing done, and the thought there was that it would help avoid unnecessary cesareans and instrumental deliveries by helping identify distressed babies earlier and more accurately. Then, when studies were finally done in the ‘80s and the ‘90s, they showed the opposite. Continuous fetal monitoring actually increases cesarean and vacuum or forceps deliveries without reducing perinatal mortality or long-term adverse neurologic outcomes for babies. The only advantage shown for continuous EFM is that it reduces the number of newborn seizures, however, that risk is already very low at 0.1%, and if it happens, as scary as that is, there don’t seem to be long-term ill effects.
Now, all this evidence led the World Health Organization, along with leading obstetric organizations in the U.K., Australia, and Canada, to issue guidelines against using routine, continuous electronic fetal monitoring for low-risk labors. ACOG, the American College of Obstetricians and Gynecologists, their statement from 2019 is less decisive, for sure, but it does open the door for using intermittent auscultation, which is a solid option with better results.
But let’s really get to the nitty gritty of how continuous EFM can affect your birth experience. Now, for some people it can be really comforting to hear the baby’s heartbeat but having those monitors on for hours on end can be hugely uncomfortable. Even though there have been some recent efforts to come up with Bluetooth versions that are less invasive, most hospitals still use that hockey-puck-like monitor that I mentioned, which often have this knob that protrudes in the center of the puck on the part that goes directly on your belly, and so to keep them on you, they usually use some elastic belts that tend to slide up and bunch up, and because these stretchy bands are trying to hold in place a flat puck that also slides around, and because they can’t put enough downward pressure on the monitor to keep it in place, the belts usually have to be tight. So, then they either dig into your back and hips, or the knob on the monitor leaves a strong indent on your belly, which I know, because clients have told me and over again, is really painful and distracting.
Second is that during labor, you and your baby are gonna be moving around a lot, which is so helpful for labor progress, but when either of you move, then the monitors may stop being able to track the heartbeat, and they need to be readjusted by the nurse. It can often take many minutes to get them back in place, which definitely interferes with your concentration and your flow, and this may happen over and over again as you or the baby continue to move.
Third is that if you don’t have access to wireless monitors, then your movement is severely limited because you’re basically tethered to a ratio of about seven feet, and sure, you can get in and out of bed, or sit on a ball next to the machine, but you can’t go for walks or get into the shower or the tub. That’s not only limiting your movement, but also your access to important non-medicated comfort measures, and my experience is that most people on continuous EFM tend to gravitate towards the bed, and we know that reclining positions can compress your aorta, which then can affect how much oxygen baby gets, and that may cause heart decels, which is what the machine is trying to pick up, and then a bunch of people are gonna rush into your room.
And that leads me to my fourth point. One of the reasons why continuous EFM remains in use is because it provides a perceived sense of safety for the hospital, the care providers, and even you, but because your EFM tracings will likely be broadcast in monitors all throughout labor and delivery, this means that a great many eyeballs are gonna be watching and ready to jump at the first sign that something is not great, which sounds like a good thing, but since EFMs can give plenty of false positives, which is when it detects something is wrong when there isn’t, this means that a bunch of people could rush into your room even though nothing might be necessarily wrong.
And this is not unusual, but it is very disconcerting. It can create stress, tension, and even fear, and since we know that it is vital for you to feel safe and secure during labor, these seemingly small interruptions can disrupt those feelings and your flow of oxytocin, which is what creates contractions.
So, what can you do? If you fall into the low-risk category, remember that routine use of continuous EFM does not make labor safer for you or your baby. And that technology cannot replace a good provider, so find a hospital and a caregiver that don’t use continuous EFM routinely, and talk to them about having intermittent fetal monitoring, or better yet, intermittent auscultation, preferably done through the use of a doppler since research has shown that the use of a handheld doppler device is a more reliable test for abnormal fetal heart rates, which is what we’re trying to get to the bottom of.
Also, when you get to the hospital, ask if they can do this auscultation during the initial intake during triage, where the common practice is to get a baseline monitoring of your baby’s heartbeat, and then ask that they continue doing that intermittent listening throughout your labor, hopefully using that handheld doppler. If you do end up using EFM for the baseline, ask how long it needs to be done for, and as soon as that time passes, call the nurse to see if you can come off the monitors. As much as I hate to say this, try not to move during that initial baseline, so that they’re able to get the continuous monitoring they’re looking for and you don’t have to be on the monitors for longer than you need to.
Do know that you don’t have to be laying down flat for that. You could be sitting on the bed, for example. Get into a position that you can comfortably hold for however long they need to do the baseline. Also, if it makes sense for you, try to avoid an induction or using an epidural, as both of those come with continuous EFM.
Now, what to do if you do have continuous monitoring. If you are on intermittent monitoring and something changed, then make sure you’re able to make an informed decision by asking about the benefits, risk, alternatives, trusting your intuition, and what would happen next if you agree. Also, ask for the possibility of coming off the continuous monitoring if your baby’s heartbeat looks fine after a set amount of time. Ask if the hospital offers wireless monitoring, as that’s gonna let you move for freely, and go to the bathroom, and maybe even get in a tub, and if that’s not an option, then ask if you can get off the continuous monitoring from time to time so you can do these things, or maybe get a shower.
Continuous fetal monitoring can also shift everyone’s attention from you to the machine, so you may want to request that the volume be turned down and put a towel over the computer readout. Basically, just try to hide it. And regardless of how long you’re on the monitors, don’t let that keep you from changing positions or moving as much as you want to. It’s the nurse’s job to accommodate the monitor to your position, not the other way around.
Now, if at any point things get scary because baby’s having the occasional decelerations, remember that your baby has reaction mechanisms, meaning if their body is pressing on the cord and they are getting less oxygen, they will tend to move to fix the situation. The hospital will also have protocols for decelerations in the heartbeat, which may include changing your position, having you get some oxygen, getting IV fluids, stopping Pitocin if that’s being used, and a few other things before changing course to a cesarean birth.
Remember, since continuous EFM can produce false positives, it can be a good option to get confirmation of the situation by having a care provider use a doppler to make sure that the monitor is reporting correctly. And finally, know that it is completely normal for babies to have heart decels during the pushing stage, and that they get a surge of noradrenaline to help them tolerate these expected moments of oxygen deprivation, because birth is supposed to work if nobody’s there, so don’t get caught up on the anxiety of the nurse during this time, as they are trying to determine if those decels are the expected kind or the concerning kind.
So, try to stay in your labor flow and continue working with your body. There is so much more we could talk about regarding continuous EFM but do check our show notes for a deep research dive if you want to know more about this topic at Birthful.com, and there you can also learn more about my birth and postpartum preparation classes. If you want to connect with Birthful on Instagram, our handle is @BirthfulPodcast.
Lozada: Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Jen Chien is executive editor. Cedric Wilson is our lead producer. Kojin Tashiro mixed this episode. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen, and come back next week for more ways to inform your intuition.
Lozada, Adriana, host. “Straight Talk about the Effects of Electronic Fetal Monitoring on You and Your Baby.” Birthful, Lantigua Williams & Co., May 5, 2021. Birthful.com.
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