How Electronic Fetal Monitoring Can Prevent Cerebral Palsy
As the parent of a child who suffers from cerebral palsy (CP), you
are well aware of this old adage. That's why you spend countless
hours reading, searching the Web and poring over new sources of
information about CP, its symptoms and advances in treatment. You
tirelessly seek any shred of knowledge that may help maximize
your child's abilities and strength, improve his health and enhance
his quality of life. When it comes to your child's wellbeing, you
don't rely solely on your doctor; you are proactive. You do your
own homework.
You recognize that there is more new and emerging information
about cerebral palsy available than any one treating physician
may know. And you understand that your doctor is focused on
treating patients He has only a limited amount of time to spend
with you.
So, you burn the midnight oil. You leave no stone unturned.
The intent of this article is to help parents better understand issues
surrounding one cause of cerebral palsy - oxygen deprivation
during labor (intrapartum asphyxia), which can lead to brain injury.
A lot of confl icting information is available about the prevalence
of intrapartum asphyxia, how to prevent it and how to lower the
risks of it occurring in future pregnancies.
There is a myth that intrapartum asphyxia is rare-a myth that
has its roots in outdated research that has been disproved in recent
years. And there is a second myth that electronic fetal monitoring
(EFM) is an unreliable way to assess the well-being of fetuses
during labor, and therefore, it doesn't help reduce the incidence
of CP. The research and opinions of many respected physicians
tell a different story.
By learning more about EFM, parents can make an informed
judgment about whether this technique was used properly during
the labor and delivery of their own child. More importantly, those
armed with this information can take knowledgeable, proactive
steps to not only ensure the safe, healthy delivery of their next baby,
but may also help ensure the baby of a friend or acquaintance has
the same chance of good health.
Let me be clear: CP can be prevented in many births. We don't
have to wait for medical science to fi nd a way to prevent every
CP occurrence. We can save many babies from developing this
heartbreaking, debilitating condition today Brain injuries during
the intrapartum period that result from decreased oxygenated
blood fl ow to the fetus often can be detected through accurate
interpretation of EFM tracings and prevented by timely, appropriate
action.
A problematic EFM pattern may require something as simple
as giving intravenous fl uids or oxygen to the mother, turning
or repositioning her, discontinuing pushing, or stopping the
administration of Pitocin (intrauterine resuscitative measures).
On the other hand, certain EFM tracings may require more serious
action, including an emergency Caesarean section.
Generally speaking, the public is unaware of electronic fetal
monitoring issues. Soon-to-be parents devour every bit of
information they can find about prenatal nutrition, exercise,
birthing centers and labor techniques. However, they often have
no understanding of the critical role that electronic fetal monitoring
can play in the outcome of their delivery.
Just as parents are encouraged to enroll in Lamaze-type classes to
learn how to ease the pain of labor and delivery, every parent also
should be schooled in the meaning of certain EFM patterns. It is
important for parents to know enough about EFM to be aware of
the right questions to ask their obstetrician and labor room nurses
about their baby's EFM tracings and how they relate to events that
may occur during labor.
Remember, knowledge is power.
Research Barriers
Generally, though, parents don't seek, nor are they encouraged
to learn this kind of information. When it comes to getting the
facts about how doctors and nurses use EFM tracings to monitor
fetuses during labor and delivery, and the proper responses to
those tracings, parents are encouraged to rely on their health care
providers.
Unfortunately, health care providers themselves are divided on
this issue, the result being that a lot of confl icting information
- even misinformation - is generated. For example, even offi cial
obstetrical documents, such as Practice Bulletin No. 62, published
by the American College of Obstetricians and Gynecologists
(ACOG), contain inaccurate data and downplay the prevalence
of cerebral palsy caused by intrapartum asphyxia, which in some
instances is preventable.
In fact, so much outdated research data and distorted information
is in circulation that it drowns out the voices of anyone who tries
to call attention to data that proves EFM can prevent many cases
of cerebral palsy. The truth about EFM is so buried in misleading
medical literature that parents seeking an accurate, complete
picture must dig deep to fi nd it.
Why the Confusion About EFM?
Popularized in the 1970s, EFM is a method for examining the
condition of an unborn infant in the uterus by noting unusual
patterns in its heart rate. EFM is a dependable measure of how
the unborn child is withstanding the changes in environment
and stimuli that it experiences during the birthing process. By
monitoring the baby's heart rate and graphing it on strips of paper,
called "tracings," doctors and labor room nurses have a realtime,
and an overall, picture of the baby's condition throughout
labor.
Statistics compiled for the year 2002 indicate that EFM was used to
monitor 85 percent of all births in United States hospitals. Many of
the other 15 percent involved natural childbirth, where the parents
opted to use midwives or to deliver their children in birthing
centers. Even in natural settings, however, when a troublesome
heart rate pattern develops during labor, those assisting with the
birth usually move the mother immediately to a facility where
EFM is available.
So, why would the medical community refute the reliability of
EFM in publications and statements, while using it so widely and
consistently?
Unfortunately, many in the medical fi eld have an agenda that
focuses more on shielding themselves or
their colleagues from accountability than
with educating patients and reducing the
risk of CP.
Clearly, their concerns are misguided. These
physicians and organizations should be a
beacon of truth and knowledge for their
patients. They should be a source of facts
for patients and, indeed, a fountainhead of
leading-edge information for parents who
want to be proactive in their health care.
But a growing number of well-credentialed
obstetricians, labor and delivery nurses, and
midwives are speaking up. These preeminent
members of the medical community, who
use EFM every day to assess the well-being
of fetuses during labor, say that EFM is viable and effective in
reducing the incidence of CP, and fetal mortality as well. The
effi cacy of EFM is demonstrated further by the continuous increase
in the percentage of births in which it is used: 45 in 1980, 62 in
1988, 74 in 1992, and 85 in 2002.
Fact Versus Fiction
Parents must realize that their quest for knowledge about their
children's health care should start before the labor and delivery
process. When you undertake your research, you will be astounded
by the misinformation you will fi nd. For instance:
Misinformation: Children rarely develop CP from asphyxial
injuries to the brain during the intrapartum period. The American
College of Obstetricians and Gynecologists claims that several
studies support the conclusion that only four percent of CP results
solely from asphyxia during labor.
Reality: The studies on which ACOG relied are inferior and
unreliable. Even if the scope of the inquiry were limited to instances
of CP where intrapartum asphyxia is the sole cause as opposed to the
primary cause, the actual percentage would be approximately three
times greater. According to Joseph J. Volpe, M.D., a Harvard
professor and Neurologist-in-Chief at Boston's Children's Hospital,
if all term infants are considered, the percentage of children
who develop CP from intrapartum asphyxia is "approximately
12 to 23 percent" which equates to "a large absolute number of
infants." Dr. Volpe concludes, further, that the "tendency in the
medical profession to deny the importance or even the existence
of intrapartum brain injury" is "particularly unfortunate," and may
well be impairing progress in CP prevention.
Misinformation: Electronic fetal monitoring has not reduced the
number of children who develop cerebral palsy.
The Corometrics Model 115 Antepartum Fetal Monitor
Reality: This false claim fails to take into account today's
enhanced survival rates of premature infants. Nationally renowned
maternal-fetal medicine specialist, Richard H. Paul, M.D. (who is
one of the pioneers in EFM), and other experts have testifi ed to the
inaccuracy of this claim in malpractice trials brought by parents
who contend that their children's cerebral palsy was caused by
medical error.
In the days before EFM and recent medical advancements, doctors
lacked the expertise and technology to save many premature babies;
generally, efforts made to save infants weighing less than three
pounds were tragically unsuccessful. Today, infants of a pound
or less receive active treatment and life support, and routinely
survive. These premature infants represent a substantial number
of the children born with CP. Yet, despite the addition of these
preemies to the survival pool, the total number of infants born with
CP has remained constant.
If the number of surviving premature babies who develop CP
has signifi cantly increased, but the total number of cases of CP
remains the same, then the number of full-term infants that have
CP must have declined. Many infants who otherwise might have
developed CP have escaped an unfortunate fate because EFM was
used properly during labor and delivery.
Misinformation: Obstetricians disagree so widely in their
interpretation of EFM tracings that standards for interpretation
and appropriate action in response to a particular EFM pattern do
not exist except in the face of tracings that are perfectlynormal or
extremely and obviously abnormal. This contention is primarily
based on three studies.
Reality: These studies are unpersuasive and outdated, with one
being more than 23 years old and each involving no more than
fi ve obstetricians. For many years, highly qualifi ed obstetricians
from all over the country have testifi ed in medical malpractice
cases that standards of care indeed do exist for the interpretation
and management of various EFM tracing patterns that fall between
those two extremes.
When EFM patterns provide evidence of impending fetal asphyxia,
such patterns need not reach the extremely abnormal level before
immediate action, such as expedited Caesarean delivery must be
taken. Yet, because medically sanctioned literature suggests that lessthan-
extreme EFM tracings don't necessarily require intervention,
many otherwise healthy babies sustain intrapartum brain injuries
and are subsequently diagnosed with CP. In connection with a
medical malpractice lawsuit brought by a Minnesota mother whose
child developed CP as a result of intrapartum asphyxia, a medical
article was uncovered that shed light on at least one reason why
doctors resist establishing written standards for the interpretation
and management of the so-called in between patterns. "Providers
have traditionally been hesitant to codify guidelines for managing
FHR [fetal heart rate] pattern tracings. The reasons commonly cited
include…fears that written guidelines will be used to scrutinize
clinical practice in a court of law."
More Misguided Priorities
As much as parents would like to believe that the best interests of
mother and baby are always the fi rst priority of the doctors and
nurses who treat them, unfortunately, other considerations possibly
come into play. According to the Association of Women's Health,
Obstetrics and Neonatal Nurses (AWHONN), nurses may hesitate
to document a physician's conduct in the medical record for fear
those notes will end up in the courtroom: "[Nurses] are usually told
by risk management personnel not to 'advertise' potential confl icts
in the medical records and thus some nurses may be unwilling to
memorialize an unsuccessful interaction with a physician…Nurses
may choose to affi rmatively protect the doctor by not documenting
an inappropriate or untimely response in the patients chart."(10)
Once parents like you learn that even a publication of a professional
nursing organization notes that its members are cautioned against
documenting potential medical errors, you will realize the gravity
of this matter and the importance of researching these issues.
A Call To Action
Signifi cant numbers of highly-qualifi ed, respected physicians have
concluded that many cases of cerebral palsy can be prevented
through the judicious use of electronic fetal monitoring. Their
positions are supported by recent medical studies that have
established a distinct relationship between certain fetal heart rate
patterns and poor neurological outcomes in infants up to a year
after birth.
And while there may be no universally agreed upon set of terms
to describe actionable EFM pattern characteristics, it is clear that
doctors know a great deal about the patterns that foreshadow CP
and other poor neonatal outcomes. By using EFM in 85 percent of
all labor and delivery rooms nationwide, the medical community
already has acknowledged EFM's value. Now, medical leaders
should take action to adopt clear-cut written protocols concerning
the interpretation of EFM tracings and appropriate interventions.
Doing so will help reduce the number of errors made in connection
with interpreting and responding to EFM tracings.
Health care organizations that promote better patient care should
develop formalized classes and seminars that focus not only on
easing the mother's pain, but also on educating parents-to-be
about EFM and other matters that will help them be proactive in
their health care.
These are complex, technical subjects, and some may be diffi cult
to research, but accurate information is available. There really are
standards, even if they have not been reduced to writing or codifi ed
by the obstetrical community. You, as parents, must do the research
necessary to learn more about EFM and its value in the labor and
delivery rooms. Remember, knowledge is power.
As I travel across the country representing parents of children with
CP, I'm often asked, "Is there anything I could have done?" Secondguessing
themselves only adds to the agony for these parents. I tell
them, "No, there's nothing you could have done." A mother and
father who have given themselves and their unborn child over to
the care of professionals should never be held accountable for what
happens in a labor and delivery room.
But what they can do to help someone else avoid what happened
to them-or to reduce the risk of the tragedy reoccurring in their
family-is an entirely different matter. Learning a few basics of EFM
is not diffi cult. It is imperative to recognize signifi cant fetal heart
rate decelerations (dips below the baseline rate) in the fetal monitor
tracings. You must also understand the relationship of decelerations
to contractions. Isolated decelerations of short duration (less than
30 seconds) generally are thought to be inconsequential. However,
if certain types of decelerations become repetitive or prolonged,
this could mean your baby is not being adequately oxygenated.
You should also realize that the presence of variability (the
second-to-second and longer-term jagged lines or variations in
the fetal heart rate tracings) is usually reassuring. On the other
hand, decreased or absent variability can be foreboding. Armed
with suffi cient knowledge, you will be able to question your health
care providers intelligently. Some AWHONN publications provide
easily understandable information about EFM patterns. Wellfounded
questions will spark your health care providers to be more
attentive to your care and that of your unborn baby.
Other important pro-active measures that parents should take
include:
Help dispel the myth that CP rarely results from
intrapartum asphyxia. It only hampers prevention efforts.
Encourage expectant couples you know, especially
those with high-risk pregnancies, to learn about EFM.
Be sure that your health care providers have the
appropriate training, certifications, and experience
necessary to properly interpret fetal monitor tracings.
Make sure your labor and delivery health care providers
know you want to be informed about evidence of reduced
fetal oxygenation and interventions that are being considered.
Confi rm that an obstetrician and anesthesiologist are inhouse
and available to respond in an emergency situation.
Understand the chain of command in the hospital so that if you
Fetal Monitoring
feel your concerns are being ignored you have an alternative
source for an opinion and intervention.
The moral for parents-to-be: Get proactive about your pregnancy
and delivery. Move past the curriculum of Lamaze classes. Learn
about more than how your baby is developing in the womb. Educate
yourselves about EFM, and learn the right questions to ask about
how your baby is being monitored during labor and delivery.
Because there really is only one certainty, and it is this: No one-no
one-cares as much about your child as you do.
source: Cerebral Palsy Magazine December 05
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