Cerebral palsy, cesarean sections, and electronic fetal monitoring: All the light we cannot see

Abstract

A half century ago electronic fetal monitoring was rushed into clinical use with the promise that the secrets of fetal heart rate decelerations had been discovered and that the newly discovered knowledge would prevent cerebral palsy with just in time cesarean sections (C-sections) preventing babies from experiencing asphyxia, which was thought to be the primary cause of cerebral palsy. In the years since electronic fetal monitoring's debut, it has been discovered that asphyxia is a rare cause of cerebral palsy. At the same time electronic fetal monitoring use increased to 85% of all labors, the C-section rate increased to 33% without an attributable decrease in the rate of cerebral palsy. What went wrong with electronic fetal monitoring? The answer lies in a new analysis of the physiologic theories concerning fetal heart rate decelerations, demonstrating that the earlier electronic fetal monitoring theories were wrong. This revelation is only the latest evidence that electronic fetal monitoring use today is harming mothers and babies with useless C-sections. Yet electronic fetal monitoring use continues unabated. Why? This article explores the complex answers and bioethical concerns, through a review of the new evidence underlying fetal heart rate decelerations in labor.

“An unnecessary cut?” multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review

“…Additional contributors to CS also include the increased use of labor-inducing drugs and the use of loco-regional anesthesia [ 25 , 26 ]. In the case of EFM, recent studies (including a meta-analysis of randomized trials) demonstrate that while continuous EFM in low-risk labor does not improve fetal outcomes, it does significantly increases the rate of CS and vaginal operative delivery [ 27 – 30 ]. Furthermore, while antenatal classes and educational programmes positively correlate to reduced chances to undergo a CS as the mode of delivery (Fig.…”

“…2002 [ 25 ] Opinion paper 3 3 na na 3 na na 3 na Low Francese al.2014 [ 26 ] Mixed Methods 4 5 5 3 4 2 4 5 32 (80%) High Macones al.2009 [ 27 ] Guideline 5 5 4 4 4 3 4 5 34 (85%) High Paterno al. 2016 [ 28 ] Scoping review 5 5 4 4 5 4 3 5 35 (88%) High Alfirevic al.2017 [ 29 ] Systematic review 5 5 4 4 5 3 5 5 36 (90%) High Sartwelle al.2019 [ 30 ] Opinion paper 3 3 na na 3 na na 3 na Low Signorelli al.1995 [ 31 ] Quantitative: observational 5 4 5 5 4 3 4 4 34 (85%) High Min Salute 2018[ 32 ] ...…”

Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis

“…In seeking to develop effective training, it must be acknowledged that the evidence‐base is likely to require more purposeful engagement with the ongoing debates and controversies regarding the value and use of CTG 14,104,105 . For instance, one reason why it may be difficult to demonstrate a positive impact of CTG training on clinical outcomes is the ongoing challenge in determining whether the use of EFM itself improves outcomes.…”

“…In seeking to develop effective training, it must be acknowledged that the evidence‐base is likely to require more purposeful engagement with the ongoing debates and controversies regarding the value and use of CTG. 14 , 104 , 105 For instance, one reason why it may be difficult to demonstrate a positive impact of CTG training on clinical outcomes is the ongoing challenge in determining whether the use of EFM itself improves outcomes. Debates continue about whether the use of CTG truly predicts cerebral palsy and other adverse birth outcomes, and whether its overall effects are positive or negative, given that the rise in caesarean section rates associated with its use has not been accompanied by decreases in rates of obstetric brain injury.…”

Electronic fetal monitoring in the twenty-first century: Language, logic and Lewis Carroll

“…[7][8][9] Yet, despite its ubiquity, it was well known that EFM never underwent any clinical trials before its introduction, was introduced without an instruction manual, without clearly defined parameters for use, and with unrealistic expectations of efficacy. [7][8][9]11,12 And while EFM's origins, theories, and the story of its invention, and the inventors' conflicts of interests, has been well documented, 7,8,[13][14][15] the reasons it was accepted into medicine without clinical trials, with little more than the inventors' anecdotes, clinical impressions, and guesses, by a profession promising to provide quality birth care to mothers and babies, is far less clear.…”