CC BY 4.0 · Surg J (N Y) 2017; 03(01): e42-e47
DOI: 10.1055/s-0037-1599229
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Ethics of Teaching Physicians Electronic Fetal Monitoring: And Now for the Rest of the Story[*]

Thomas P. Sartwelle
1   Deans and Lyons, LLP, Houston, Texas
,
James C. Johnston
2   Private Practice, San Antonio, Texas
3   Global Neurology Consultants, Auckland, New Zealand
,
Berna Arda
4   Department of Medical Ethics, University of Ankara, Ankara, Turkey
› Author Affiliations
Further Information

Publication History

02 December 2016

23 January 2017

Publication Date:
20 March 2017 (online)

Abstract

Electronic fetal monitoring (EFM) does not predict or prevent cerebral palsy (CP), but this myth remains entrenched in medical training and practice. The continued use of this ineffectual diagnostic modality increases the cesarean section rate with concomitant harms to mothers and babies alike. EFM, as it is used in defensive medical practice, is a violation of patient autonomy and raises serious ethical concerns. This review addresses the need for improved graduate medical education so that physicians and medical residents are taught both sides of the EFM–CP story.

* The Rest of The Story was a Monday-Friday radio program featuring Paul Harvey. Beginning in WWII, Harvey would narrate a little known or forgotten story of history, leaving a key element, like the name of a well-known person, until the very end of the narration, concluding with the now famous tag line “And now you know the rest of the story.”[1]


 
  • References

  • 1 Harvey Jr P. The Rest of the Story. New York, NY: Bantam Books; 1997
  • 2 Freeman JM. , ed. Prenatal and Perinatal Factors Associates With Brain Disorders. Bethesda, MD: U.S. Department of Health and Human Services; 1985
  • 3 Meunier MR, Angstman KB, Mullan PB. Teaching residents electronic fetal monitoring: a national needs assessment. Fam Med 2015; 47 (06) 445-451
  • 4 Nelson KB, Sartwelle TP, Rouse DJ. Electronic fetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence. BMJ 2016; 355: i6405
  • 5 Lear CA, Galinsky R, Wassink G. , et al. The myths and physiology surrounding intrapartum decelerations—the critical role of the peripheral chemoreflex. J Physiol 2016; 594 (17) 4711-4725
  • 6 Sartwelle TP, Johnston JC, Arda B. Electronic fetal monitoring, cerebral palsy litigation, and bioethics: the evils in Pandora's box. J Ped Care 2016; 2 (14) 1-7
  • 7 MacLennan AH, Thompson SC, Gecz J. Cerebral palsy: causes, pathways, and the role of genetic variants. Am J Obstet Gynecol 2015; 213 (06) 779-788
  • 8 Donn SM, Chiswick ML, Fanaroff JM. Medico-legal implications of hypoxic-ischemic birth injury. Semin Fetal Neonatal Med 2014; 19 (05) 317-321
  • 9 Costantine MM, Saade GR. The first cesarean: role of “fetal distress” diagnosis. Semin Perinatol 2012; 36 (05) 379-383
  • 10 Grimes DA, Peipert JF. Electronic fetal monitoring as a public health screening program: the arithmetic of failure. Obstet Gynecol 2010; 116 (06) 1397-1400
  • 11 Badawi N, Keogh JM. Causal pathways in cerebral palsy. J Paediatr Child Health 2013; 49 (01) 5-8
  • 12 Greene MF. Obstetricians still await a deus ex machina. N Engl J Med 2006; 355 (21) 2247-2248
  • 13 MacLennan A, Nelson KB, Hankins G, Speer M. Who will deliver our grandchildren? Implications of cerebral palsy litigation. JAMA 2005; 294 (13) 1688-1690
  • 14 Beller FK. The cerebral palsy story: a catastrophic misunderstanding in obstetrics. Obstet Gynecol Surv 1995; 50 (02) 83-86
  • 15 Sartwelle TP, Johnston JC, Arda B. Perpetuating myths, fables, and fairytales: a half century of electronic fetal monitoring. Surg J 2015; 01 (01) e28-e34
  • 16 Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy--fact and fiction. Am J Obstet Gynecol 2003; 188 (03) 628-633
  • 17 Benson RC, Shubeck F, Deutschberger J, Weiss W, Berendes H. Fetal heart rate as a predictor of fetal distress. A report from the collaborative project. Obstet Gynecol 1968; 32 (02) 259-266
  • 18 Obladen M. Lame from birth: early concepts of cerebral palsy. J Child Neurol 2011; 26 (02) 248-256
  • 19 Vreeman RC, Carroll AE. Festive medical myths. BMJ 2008; 337: a2769
  • 20 Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA 2012; 307 (01) 37-38
  • 21 Prasad V, Gall V, Cifu A. The frequency of medical reversal. Arch Intern Med 2011; 171 (18) 1675-1676
  • 22 Graham EM, Petersen SM, Christo DK, Fox HE. Intrapartum electronic fetal heart rate monitoring and the prevention of perinatal brain injury. Obstet Gynecol 2006; 108 (3 Pt 1): 656-666
  • 23 Banta DH, Thacker SB. Historical controversy in health technology assessment: the case of electronic fetal monitoring. Obstet Gynecol Surv 2001; 56 (11) 707-719
  • 24 Block J. Pushed: The painful truth about childbirth and modern maternity care. Chp. 1, Arranged Birth: 31–38. Cambridge, MA: DaCapo Press; 2007
  • 25 Goer H, Romano A. Optimal care in childbirth. In: Electronic Fetal Monitoring (Cariotocography): Minding the Baby. Seattle, WA: Classic Day Publishing; 2012: 223-250
  • 26 Scheller JM, Nelson KB. Does cesarean delivery prevent cerebral palsy or other neurologic problems of childhood?. Obstet Gynecol 1994; 83 (04) 624-630
  • 27 Sartwelle TP, Johnston JC. Cerebral palsy litigation: change course or abandon ship. J Child Neurol 2015; 30 (07) 828-841
  • 28 Sartwelle TP. Electronic fetal monitoring: a bridge too far. J Leg Med 2012; 33 (03) 313-379
  • 29 Clark SL, Nageotte MP, Garite TJ. , et al. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013; 209 (02) 89-97
  • 30 Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. N Engl J Med 1996; 334 (10) 613-618
  • 31 Alfirevic A, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2006; 19 (03) CD006066
  • 32 Am. Coll. Obstet. & Gynecol. & Am. Acad. Pediatricians. Neonatal encephalopathy and neurologic outcome. Pediatrics 2014; 133 (05). DOI: 10.1542/peds.2014-0724.
  • 33 Sartwelle TP, Johnston JC. Neonatal encephalopathy 2015: opportunity lost and words unspoken. J Matern Fetal Neonatal Med 2016; 29 (09) 1372-1375
  • 34 MacDonald D. Cerebral palsy and intrapartum fetal monitoring. N Engl J Med 1996; 334 (10) 659-660
  • 35 Thacker SB, Stroup DF, Peterson HB. Efficacy and safety of intrapartum electronic fetal monitoring: an update. Obstet Gynecol 1995; 86 (4 Pt 1): 613-620
  • 36 Jenkins HM. Thirty years of electronic intrapartum fetal heart rate monitoring: discussion paper. J Royal Soc Med 1989; 82 (04) 210-214
  • 37 Freeman R. Intrapartum fetal monitoring--a disappointing story. N Engl J Med 1990; 322 (09) 624-626
  • 38 Sartwelle TP, Johnston JC. Cerebral palsy and electronic fetal monitoring: rearranging the Titanic's deckchairs. J Child Develop Disord 2016; 2 (01) 1-10
  • 39 Belfort MA, Saade GR, Thom E. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. A randomized trial of intrapartum fetal ECG ST-segment analysis. N Engl J Med 2015; 373 (07) 632-641
  • 40 Van Naarden Braun K, Doernberg N, Schieve L, Christensen D, Goodman A, Yeargin-Allsopp M. Birth prevalence of cerebral palsy: a population-based study. Pediatrics 2016; 137 (01) e20152872
  • 41 MacLennan AH. A ‘no-fault’ cerebral palsy pension scheme would benefit all Australians. Aust N Z J Obstet Gynaecol 2011; 51 (06) 479-484
  • 42 Nelson KB, Blair E. Prenatal factors in singletons with cerebral palsy born at or near term. N Engl J Med 2015; 373 (10) 946-953
  • 43 Natale R, Dodman N. Birth can be a hazardous journey: electronic fetal monitoring does not help. J Obstet Gynaecol Can 2003; 25 (12) 1007-1009
  • 44 Trimbos JB, Keirse MJ. Observer variability in assessment of antepartum cardiotocograms. Br J Obstet Gynaecol 1978; 85 (12) 900-906
  • 45 Borgatta L, Shrout PE, Divon MY. Reliability and reproducibility of nonstress test readings. Am J Obstet Gynecol 1988; 159 (03) 554-558
  • 46 Nielsen PV, Stigsby B, Nickelsen C, Nim J. Intra- and inter-observer variability in the assessment of intrapartum cardiotocograms. Acta Obstet Gynecol Scand 1987; 66 (05) 421-424
  • 47 Sabiani L, Le Dû R, Loundou A. , et al. Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management. Am J Obstet Gynecol 2015; 213 (06) 856.e1-856.e8
  • 48 Sholapurkar SL. Interpretation of British experts' illustrations of fetal heart rate decelerations by Consultant Obstetricians, registrars and midwives: a prospective study—reasons for major disagreements with the experts and implications for clinical practice. Open J Obstet Gynecol 2013; 3: 454-465
  • 49 Hruban L, Spilka J, Chudáček V. , et al. Agreement on intrapartum cardiotocogram recordings between expert obstetricians. J Eval Clin Pract 2015; 21 (04) 694-702
  • 50 Spilka J, Chudáček V, Janků P. , et al. Analysis of obstetricians' decision making on CTG recordings. J Biomed Inform 2014; 51: 72-79
  • 51 Devoe LD. Electronic fetal monitoring: does it really lead to better outcomes?. Am J Obstet Gynecol 2011; 204 (06) 455-456
  • 52 American College Obstetricians & Gynecologists and Society for Maternal Fetal Medicine. Safe prevention of the primary cesarean section. Am J Obstet Gynecol 2014; 123: 179-193
  • 53 Osterman MJK, Kochanek KD, MacDorman MF, Strobino DM, Guyer B. Annual summary of vital statistics: 2012-2013. Pediatrics 2015; 135 (06) 1115-1125
  • 54 Banta HD, Thacker SB. Assessing the costs and benefits of electronic fetal monitoring. Obstet Gynecol Surv 1979; 34 (08) 627-642
  • 55 Graham EM, Adami RR, McKenney SL, Jennings JM, Burd I, Witter FR. Diagnostic accuracy of fetal heart rate monitoring in the identification of neonatal encephalopathy. Obstet Gynecol 2014; 124 (03) 507-513
  • 56 Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol 2012; 120 (05) 1181-1193
  • 57 Am. Coll. Obstet. & Gynecol. & Am. Acad. Pediatricians. Neonatal encephalopathy and cerebral palsy: defining the pathogenesis and pathophysiology. Obstet Gynecol 2003; 102 (03) 628-636
  • 58 Zwecker P, Azoulay L, Abenhaim HA. Effect of fear of litigation on obstetric care: a nationwide analysis on obstetric practice. Am J Perinatol 2011; 28 (04) 277-284
  • 59 O'Callaghan M, MacLennan A. Cesarean delivery and cerebral palsy: a systematic review and meta-analysis. Obstet Gynecol 2013; 122 (06) 1169-1175
  • 60 Localio AR, Lawthers AG, Bengtson JM. , et al. Relationship between malpractice claims and cesarean delivery. JAMA 1993; 269 (03) 366-373
  • 61 Ecker J. Elective cesarean delivery on maternal request. JAMA 2013; 309 (18) 1930-1936
  • 62 Silver RM, Fox KA, Barton JR. , et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212 (05) 561-568
  • 63 Chaillet N, Dumont A, Abrahamowicz M. , et al; QUARISMA Trial Research Group. A cluster-randomized trial to reduce cesarean delivery rates in Quebec. N Engl J Med 2015; 372 (18) 1710-1721
  • 64 Borre YE, O'Keeffe GW, Clarke G, Stanton C, Dinan TG, Cryan JF. Microbiota and neurodevelopmental windows: implications for brain disorders. Trends Mol Med 2014; 20 (09) 509-518
  • 65 Neu J. The pre- and early postnatal microbiome: relevance to subsequent health and disease. Neoreviews 2013; 14 (12) e592-e599
  • 66 Friedrich MJ. Unraveling the influence of gut microbes on the mind. JAMA 2015; 313 (17) 1699-1701
  • 67 Sevelsted A, Stokholm J, Bønnelykke K, Bisgaard H. Cesarean section and chronic immune disorders. Pediatrics 2015; 135 (01) e92-e98
  • 68 Abrams JR. The illusion of autonomy in women's medical decision making. Fla State Univ Law Rev 2015; 42: 17-60
  • 69 Heelan L. Fetal monitoring: creating a culture of safety with informed choice. J Perinat Educ 2013; 22 (03) 156-165
  • 70 Wood SH. Should women be given a choice about fetal assessment in labor?. MCN Am J Matern Child Nurs 2003; 28 (05) 292-298 , quiz 299–300
  • 71 Rhoden NK. Informed consent in obstetrics: some special problems. West New Engl Law Rev 1987; 9 (01) 67-88
  • 72 Gilfix MG. Electronic fetal monitoring: physician liability and informed consent. Am J Law Med 1984; 10 (01) 31-90
  • 73 Veatch RM. The Basics of Bioethics. 3rd ed. Boston, MA: Pearson Education; 2012
  • 74 Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press; 2009
  • 75 Jonsen AR. A Short History of Medical Ethics. New York, NY: Oxford University Press; 2000
  • 76 Spatz ES, Krumholz HM, Moulton BW. The new era of informed consent. JAMA 2016; 315 (19) 2063-2064
  • 77 Grady C. Enduring and emerging challenges of informed consent. N Engl J Med 2015; 372 (09) 855-862
  • 78 Schenker Y, Meisel A. Informed consent in clinical care: practical considerations in the effort to achieve ethical goals. JAMA 2011; 305 (11) 1130-1131
  • 79 Zuspan FP, Quilligan EJ, Iams JD, van Geijn HP. Predictors of intrapartum fetal distress: the role of electronic fetal monitoring. Report of the National Institute of Child Health and Human Development Consensus Development Task Force. Am J Obstet Gynecol 1979; 135 (03) 287-291
  • 80 International Federation of Gynaecology and Obstetrics. Guidelines for the use of fetal monitoring. Int J Gynaecol Obstet 1987; 25: 159-167
  • 81 Fahey MC, MacLennan AH, Kretzschmar D, Gecz J, Kruer MC. The genetic basis of cerebral palsy. Dev Med Child Neurol 2016; (e-pub ahead of print). DOI: 10.1111/dmcn.13363.
  • 82 Byrne J, Straub H, DiGiovanni L, Chor J. Evaluation of ethics education in obstetrics and gynecology residency programs. Am J Obstet Gynecol 2015; 212 (03) 397.e1-397.e8