New Fetal Monitoring Guidelines Won’t Prevent Cerebral Palsy

13 Jul New Fetal Monitoring Guidelines Won’t Prevent Cerebral Palsy

In the July 2009 issue of Obstetrics & Gynecology, a trade and medical research publication, the American College of Obstetricaisn and Gynecologists released refined definitions, classifications, and interpretations of fetal heart rate monitoring.
Before getting too far into the technical, we should state simply that we don’t agree with these self-protecting guidelines. As OBGYNs move into a cocoon of fuzzy data and interpretation, mothers, children, and families affected by cerebral palsy are left in the cold.

A quick overview before jumping into the issues raised with the new guidelines: fetal heart rate monitoring can be accomplished by two different mechanisms – electronic fetal monitoring (EFM) or manual auscultation with a fetoscope. EFM is the most common obstetric procedure with more than 85% of pregnant women in labor hooked up to these machines. The results of an EFM are much like an electrocardiograph – all it does is measure the heart rate and strength of the heartbeat of the soon-to-be-born fetus.

EFM was introduced in the 1970s to monitor potential situations of fetal distress. Fetal heart rates below 110 beats per minute or above 160 beats per minute are considered abnormal. However, abnormalities may come and go, depending on the mother’s situation, position, stress level, injection of pain medications, or any number of other characteristics, including uterine contractions.

To combat these variations, doctors have looked at two factors: long-term and short-term variability in fetal heart rate in determining an appropriate course of action during the birthing process. This analysis was performed regularly throughout labor, looking at a short and long course of data to detect abnormalities and potential fetal distress.

But the system wasn’t perfect. Though the analysis can show statistical abnormality, interpretation of abnormalities varies widely. This is seen in the cerebral palsy incidence rates: since World War II, the rate of cerebral palsy has remained unchanged despite advances in technology and monitoring. Given this data, it begs the question – is EFM effective in reducing the rate of cerebral palsy?

The answer is convoluted. The interpretation of EFM is highly subjective and given an abnormal fetal heart rate, only one or two babies will be later diagnosed with cerebral palsy out of every thousand born. Nearly 70% of cerebral palsy cases are due to complications before labor begins; 4% are due to complications during labor and delivery; and the remaining 26% are due to a combination of factors throughout the pregnancy, labor, delivery, and more.

The new guidelines, however, add to the subjectivity of EFM monitoring. Rather than use the “reassuring” or “nonreassuring” nomenclature of the past, the guidelines split monitoring into three categories: normal, indeterminate, and abnormal.

Yet these categories are fuzzy and vague, allowing the interpreter much more leeway in analysis without taking into account possible risks for incorrect, indeterminate, or inaccurate interpretation. With regard to a cerebral palsy case, these categories do nothing more but add intraspeciality disagreement among doctors – meaning that expert witnesses still disagree with one another about whether or not a doctor should have interpreted the data in a more responsible manner, resulting in a unclear malpractice case. How can one identify a malpractice case if there’s no clear guideline as to what is/what isn’t malpractice?

And a better question: why continue to use a technology that cannot adequately predict the onset of cerebral palsy? The new guidelines provide little insight as to how continued use of this technology will help prevent cerebral palsy or other fetal distress-related conditions.

And yet another observation: the guidelines use the term “approximately” in the segmentation of monitoring. How often should a doctor check in on the pregnant woman in labor? Somewhere, approximately, between every five and thirty minutes. But what fits in the range of “approximately” – we don’t know either, leading to more fuzzy argument and little hope for a reasonable and predictable outcome.