Really, TNR? Is this hatchet job on electronic fetal monitoring what passes for journalism these days?

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Apparently the author started with the conclusions, spoke only to those who would support that conclusion, and failed to consult even a single expert on the topic to produce a hatchet job on electronic fetal monitoring (EFM).

Noah Berlatsky wrote The Most Common Childbirth Practice in America Is Unnecessary and Dangerous for The New Republic (TNR).

…[W]hy despite decades of overwhelming evidence, do doctors and patient alike continue to insist on this largely useless and sometimes dangerous procedure?

The obvious answer is that the author doesn’t understand the issue. What’s more likely, that obstetricians are engaged in a world-wide plot to harm mothers and babies, or that Noah Berlatsky, a journalist with no medical training, doesn’t understand the state of the evidence?

An author writes a piece decrying obstetric technology without ever consulting an obstetrician and editors think that is acceptable?

You might think, therefore, that the editors at TNR would have considered that Berlatsky didn’t understand what he was talking about, and insisted on consultation with and quotes from experts in the issue, obstetricians. You would be wrong. It was awesome click-bait, one sided and shocking. They published it, and when the deficiencies of the piece were pointed out to Berlatsky, he resorted to name calling, deleting and blocking.

The piece reads as if Berlatsky consulted only the natural childbirth industry who profit by demonizing modern obstetrics. And, indeed, that is precisely what he did. He quoted midwives and an executive from the Childbirth Connection, the largest natural childbirth lobbying organization. Then he reached out to lay midwives searching for EFM bad outcomes with which to frame his piece.

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…I’m interested in hearing from women who have had negative experiences with fetal monitoring. For example, if monitoring led to an unnecessary Cesarean, or also if fetal monitoring missed a problem and led doctors to think all was well when it wasn’t…

There is so much wrong with the piece that I can’t recount it all. The single biggest problem with it is that the issue of EFM is complicated, nuanced and poses difficult choices. To understand that issue, you need to understand what EFM is and why it was created.

Childbirth is inherently dangerous. The day of birth is the single most dangerous day of the 18 years of childhood. Every newborn death is a dreadful tragedy, but the cruelest form of newborn death may be stillbirth during childbirth. A woman labors in agony for hours, pushes with all her strength to expel the baby and finally the baby is born … dead. During labor, the baby was deprived of oxygen (fetal distress) and died. If the baby had been delivered by C-section, it almost certainly would have survived.

Before C-sections became very safe, the issue was moot. There was no point in monitoring the baby during labor if you couldn’t do anything to save the baby. The advent of safe C-sections gave impetus to efforts to diagnose fetal distress and deliver babies before they could be harmed or killed.

Unfortunately, unborn babies are inaccessible. You can’t measure their oxygen levels, or their blood pressure, or examine them. The only thing you can measure is their heart rate. Determining health from heart rate is exceedingly difficult and imprecise. You have to listen at the right times and for long enough to detect harmful changes; electronic fetal monitoring was designed to monitor the fetal heart rate for long periods and to create a written record.

Fetal monitoring, first using handheld listening devices and later using EFM, essentially eliminated stillbirth in labor. This success in nearly eliminating stillbirth in labor encouraged obsetricians to believe that they could eliminate cerebral palsy if they monitored more, longer and with more sophisticated techniques. It wasn’t until EFM was in widespread use that we came to understand that while oxygen deprivation causes cerebral palsy, oxygen deprivation is not the only thing that can cause cerebral palsy.

So where are we know?

1. Fetal monitoring, using listening devices or EFM, has been spectacularly successful in preventing stillbirth during labor.

2. EFM has very high sensitivity. If a baby is experiencing oxygen deprivation, EFM will alert providers.

3. We have come to understand the EFM has low specificity. That means that it can signal fetal distress when no distress is present, leading to unnecessary C-sections.

4. EFM provides proven benefits in high risk pregnancies. That’s not surprising since EFM is a screening test and all screening tests are more accurate in high risk populations than in low risk populations.

5. EFM can probably prevent some forms of cerebral palsy, but many probably occur before the onset of labor and EFM can’t prevent those cases.

6. In low risk populations, EFM probably provides no advantage above listening to the fetal heart rate following a strict pattern of frequent listening, which essentially requires one on one nursing in labor and delivery suites. This is a critical point: Even in low risk populations EFM is not useless, it’s just no better than listening to the heart rate according to a strict schedule. And in high risk populations, EFM has been repeately shown to improve outcomes.

7. There is no evidence that EFM is dangerous. To be dangerous, EFM would have to lead to poorer outcomes and it does NOT lead to poorer outcomes. Why then do natural childbirth advocates demonize EFM? The reason is not outcome, but process. Natural childbirth advocates are obsessed with process and take a good outcome for granted. Doctors are more concerned with outcome than process, and eons of human history have shown that a good outcome can never be taken for granted.

8. Oxygen deprivation in labor is still a serious problem requiring our best efforts to prevent it. Is EFM the best possible tool to prevent oxygen deprivation? It’s not the best, but at the moment, it’s one of the few things we have.

Berlatsky and his those he chose to quote are anxious to demonize EFM, but they don’t appear to be the least bit concerned about how to prevent brain damage and infant death. They don’t offer other better methods to protect babies; it appears to never enter their minds that there is anything that can or should be done to protect babies.

And that’s the critical difference between natural childbirth advocates like Berlatsky and the people he quotes and obstetricians. They’re willing to settle for things the way they are now; that’s good enough for them. Obstetricians are NOT willing to settle. They want every baby they deliver to be healthy; they want every mother they deliver to be healthy. They will continue working toward that end.

In the meantime, people like Berlatsky, who doesn’t understand the underlying issues, will continue writing crappy pieces that demonize technology; and continue to pretend that obstetrics ought to be like horse-shoes and hand grenades: close enough is good enough. Berlatsky is entitled to his uninformed opinion; but there was no reason for TNR to publish such a misleading, unbalanced, biased piece.

An author writes a piece decrying obstetric technology without ever consulting an obstetrician and editors think that is acceptable? If so, journalism has reached a sorry state.

  • Maya

    Electronic fetal monitoring saved my son; we’d been laboring well for fourteen hours when the cord was compromised. EFM picked it up; the nurse held him off the cord, while the room filled with people, and his heart rate returned to normal a few minutes later (while they were prepping me for a section, which didn’t then happen.) He’s two now, and perfectly healthy. I describe his birth as “with more drama than strictly speaking necessary.” I had nightmares about those six minutes for weeks after his birth. The only thing that calmed me down at the time was the fact that I could go and kiss his beautiful, living head.

  • Daleth

    Obstetricians are NOT willing to settle. They want every baby they deliver to be healthy; they want every mother they deliver to be healthy.

    And that’s why I prefer obstetricians. Not CPMs who say “some babies weren’t meant to live,” or who tell a widower grieving the death of his wife in a home birth that they hope he finds comfort in the fact that right BEFORE she bled to death, she had a beautiful home birth.

    http://www.dailymail.co.uk/health/article-2198725/Claire-Teague-death-Wife-bleeds-death-midwife-Rosie-Kacary-persuaded-homebirth.html

    • Kelly

      That is so terrible. I am glad the father is trying to get justice. There were so many errors in that delivery. I am glad that even if my doctor messed up like this, I would have nurses to catch it. The nurses and other doctors would not back up that doctor either.

    • Mattie

      That is disgusting, so disgusting. What is even the point of checking the placenta if you’re then not going to do anything when it isn’t complete. This midwife needs to be struck off like yesterday, revolting.

      • KeeperOfTheBooks

        Struck off, and I should think charged with whatever the UK’s version is of negligent homicide, or some such. Examined the placenta in the DARK, and then decided that the rest of it–you know, over a THIRD of it?!–would just wander out on its own? What the hell?

        • Mattie

          Yes, I hope so. I just don’t understand the idea behind the checking if you’re not going to do anything anyway…why check? The entire effing point of checking the placenta is to ensure none is left in arghhh

          • KeeperOfTheBooks

            And again, still not a medical professional here, but even I know that all the placenta has to be removed after birth, and that fairly quickly because the uterus doesn’t clamp down appropriately until it’s gone.
            What. the. hell.

      • Roadstergal

        “This midwife needs to be struck off like yesterday, revolting.”

        It said in the article that she’s practicing as a private midwife – I dunno how that all works in the UK.
        I don’t know where to start, continue, or conclude with the amount of clusterfuck she caused, even giving a dose of salt to the Mail for hyperbole.

        • Mattie

          Private/independent midwives are not employed by the NHS but are regulated in the same way as NHS midwives by the NMC, so she will be subject to the same education and practice standards as any other midwife (thank god) so she will be punished, whether by court as well as by the NMC is yet to be seen but hopefully she will face criminal charges too.

          • Roadstergal

            Ah, thanks for the info – so even private midwives are supposed to know better…

          • Mattie

            Hell yes. I do often wonder though how much the requirements are enforced with IMs in certain areas, whether it is easier for them to ‘slip through the net’ as it were and get away with crap practice and no continuing education.

  • carovee

    Obstetricians are NOT willing to settle. They want every baby they
    deliver to be healthy; they want every mother they deliver to be
    healthy. They will continue working toward that end.

    That’s such an important point, and applies pretty much to most alt woo. They aren’t interesting in researching and inventing better ways provide care, they just peddle what they have as if its good enough forever.

    When I was in active labor the nurse moved me from one position to another. The babies heart dropped and they changed me back immediately. Was he really in distress? Who knows but why take the chance? I’ve never understood what was supposed to be so terrible about EFM except that you might not get to move around as much.

  • attitude devant

    What ever became of fact checkers? Oh wait, this is TNR, the mag that failed to rein in Stephen Glass with even minimal editorial supervision, leading toone of the biggest journalism scandals of the 1990s. Looks like they haven’t learned from past mistakes.

  • Lizzie Dee

    Isn’t it the case that MORE EFM would result in fewer stillbirths/bad outcomes? Logistically difficult, perhaps, as its main benefit is in high risk cases. But “trusting birth” and the assumption that low risk is a state of mind that can be achieved by a “natural” approach and eating lots of kale could do with being abandoned.

    How long is it since that study on the effect of EFM on reducing CP was done? Who did it? I know it was about the same time as the rather convenient study that decided that CP was caused by other rather
    mysterious things that didn’t lead to medical negligence claims, and when
    interpreting EFM wasn’t as good as it is now.

    I read a case recently, here in England. First child, mother wanted an all natural home birth. Low risk, why not? Around 36 weeeks, feeling unwell, called the professional, well trained midwives. They assured her that
    headaches, blurred version, and high blood pressure were all part of normal, and didn’t even do a urine test. The mother had the sense to get herself to the hospital a week later. She now has a child with mild CP, severe cognitive problems. Lost the negligence case. NHS admitted negligence, denied causation. No EFM traces.

    • Mattie

      Urgh, that’s so sad 🙁 she was presenting with such obvious problem symptoms, they literally did not even need to check her themselves, they just had to tell her to go to the hospital…when I was on placement the amount of times we would tell women ‘if you have a headache that does not get better with painkiller, any visual disturbances, you feel generally unwell, you get any epigastric pain etc…” go straight to delivery suite and get them to check you and the baby. The midwives and doctors on DS would literally rather check and reassure 100 healthy women than miss 1 unwell woman and have something horrible happen….the training for midwives and ongoing CPD needs to be seriously improved.

      • KeeperOfTheBooks

        Hell, I’m no healthcare professional, and *I* can tell you that if a pregnant friend called me and said she had a bad headache/blurred vision, I’d say “Get thee to your OB or L&D ward this second, and do you have someone to drive you or am I picking you up?”

  • Lawyer jane

    UGH now he is arguing that epidurals lead to c-section. Seriously dude just STOP. How anti-feminist can he get?

    • Anj Fabian

      If you want to know the answer to that, read his other articles.

      I don’t recommend that because I’ve tried to read his other articles and he specializes in mansplaining issues to women.

    • Montserrat Blanco

      So, someone that will never ever experience that pain is telling people that might experience that pain or have experienced that pain themselves to do not get pain relief.

      If I do that with my patients at my hospital I will get sacked on the spot.

    • Sue

      Even if it were true, it would mean that effective pain relief MAY be associated with birth that leads to better neonatal outcomes.

    • Sarah

      Let me be the first to say, even if that were true, so fucking what?

  • Kelly

    Finally read the actual article and that is so very bad. People are claiming that Dr. Amy does not even link to research when I did not see a single link in there about how EFM is ineffective. It just does not make sense that continuous monitoring does not save lives. How else are we to know if a baby is on the verge of death? I do not want my baby coming out gray and floppy. I would rather have the unnecessarian.

  • Kazia

    Am I the only one who thought TNR referred to trap-neuter-return, a technique used to reduce feral cat populations?

    • DaisyGrrl

      You are not. I was scratching my head on this one as well. 🙂

  • Petanque

    But if women are using technology to gather information and make logical decisions it means our mysterious “other-ways-of-knowing” glands will wither away, and then where would we be??!!

    • Mattie

      I actually think parents with toddlers/young children have those glands in tip top shape, they always seem to know when something is up…at least my parents did haha

      • Roadstergal

        I think with a toddler, the secret could be “If s/he can be up to something, s/he is.” Like EFM, it’s more sensitive than specific, but the false positive rate is surely quite low… I know that worked pretty well on me as a teen, come to that. :p

        • KeeperOfTheBooks

          It’s low. Believe me, it’s low. And I say this as a mom of a relatively well-behaved toddler. *thanks the gods of nap-dom that DD is finally down for her nap*

  • KarenJJ

    Mansplainers really don’t like women that disagree with them, do they?

    • Sarah

      We had an absolute peach on one of the recent breastfeeding threads. Anyone who complained was trivialising real sexism and/or not understanding it.

  • anotheramy

    Thanks, Dr. Amy, for this very detailed explanation. Posts like this are why I started coming to your blog-to get more info.

  • Gatita

    So I have a question: how do you measure if the morbidity and mortality from more c-sections being performed is greater or less than the m/m that results from not using EFM?

    • nomofear

      Uhhh…human history?

      • Gatita

        This makes me cranky. I’m not anti-intervention at all. I’m asking a legit question–how do you study this intervention? How do you design the research to control for confounders and determine the benefit?

        • Dr Kitty

          It would have to be a case-control retrospective study, but it would be extremely difficult to case match.

          If you case match demographics, you’ll have someone with a two hour labour of an 8lb baby and no interventions matched with a 48 hr labour with a 6lb baby, CEFM and an epidural and an eventual CS for foetal distress. Now, how do you decide if the CEFM “caused” the CS in case 2?

          If you case match for labour and not for demographics, your risks will be messed up.

          If you case match for demographics, size of baby, position of baby, underlying risks, restrict it to primips and have the ONLY difference be CEFM vs good quality intermittent auscultation, you’d have a very rigorous, but completely unfeasible study.
          The amount of data you would need to prove causation would be HUGE and complex.

          Or you can do what the UK has done, which is say that CEFM is not to be used for any low risk deliveries, and then you can compare your outcomes for the five years after the start of the policy, with your outcomes for the five years before it…and hope you did the right thing.

          • Roadstergal

            “Or you can do what the UK has done, which is say that CEFM is not to be used for any low risk deliveries, and then you can compare your outcomes for the five years after the start of the policy, with your outcomes for the five years before it…”

            Just to clarify – CEFM was being used in all pregnancies, including low risk, for over 5 years, and then they stopped?

          • Dr Kitty

            No, sorry, I should have been clearer.
            CEFM was being used in high risk pregnancies, and any low risk labour where it was requested by the mother, or was felt to be more appropriate than intermittent auscultation, for whatever reason.
            Basically, if the labouring woman, or midwives or OB wanted CEFM, it happened, even without any obvious risk factors, and most people had at least 30 minutes CEFM on admission to the labour unit, before moving to IA if all was well.

            The guidance is now very clear that CEFM not be used in any low risk pregnancy, full stop. Which is a big change, but not as big as I implied.

          • Roadstergal

            Ah, gotcha. It’s going to be very tough to pull any data out of that, for sure. If nothing else, there’s a lot totally unrelated to CEFM that can change in terms of patient populations and practices in 10 years…

            Was the decision motivated by cost?

          • Dr Kitty

            Not obviously.
            NICE cites that data doesn’t support CEFM being associated with better outcomes in low risk pregnancies in the updated intrapartum guideline.

          • Ash

            I wonder if intermittent monitoring is not cost effective given staffing shortages–at some points you have to monitor frequently enough that it’s essentially one to one care, right? Cardiac units monitor multiple patients thru telemetry at a central station, is that not true for EFM?

    • And, on top of what nomofear said, you look at m&m rates for women who had EFM and those who didn’t. You try your best to deal with confounding factors as well, because maybe women who reject EFM have other characteristics that make them at higher risk of complications and maybe they have other characteristics that make them at lower risk of complications. Studies that have done this show a significant decrease in neonatal mortality using EFM (I believe).

      It is unethical to do a randomized study. Because we know EFM saves lives, would you like to be the one to explain to a new loss mother that her baby died because she was randomized into a trial that deliberately didn’t use the latest and greatest technology to monitor her baby?

      • Gatita

        Gimme a freakin’ break. This actually pisses me off because I’m asking a legit question. Those of you who work with stats and research: how do you study EFM in such a way to measure benefits to babies weighed against morbidity/mortality to mothers? I did a search on Google Scholar and didn’t find much so if someone has a real answer, not a snotty, condescending answer, I’d like to see it.

        • Karen in SC

          I didn’t read any condescension at all in the reply. I understood the explanation pretty well as to why a randomized trial could not be conducted. Retrospective data can be used, but there will be many confounders to account for.

          • Wren

            I agree. I didn’t see condescension either, but I did see a huge overreaction.
            Since a RCT cannot be done on this issue, a retrospective study is pretty much the best answer. Yes, there will be loads of confounders, same as most other studies done in this way.

          • toni

            I can see that the way she said it… “would *you* like to be the one to explain to a new loss mother….?” could be taken as a bit, idk, accusatory. Didn’t we recently have a discussion about the pros and cons of routine mammograms? It’s the same sort of question.. at what point would we see overall worse outcomes because of too vigilant monitoring. How many painful procedures is worth one life. (I would have a million CS to save my baby but that’s not a helpful guide on a population basis) If someone was all like well how would YOU like to explain to the kids who lost their mum to cancer that she died because she didn’t get her mammogram the other poster would feel defensive? I’m sure feminerd didn’t mean it that way but internet discussions have their pitfalls.

        • That wasn’t a snotty, condescending answer. That’s how you would set up such a study. I don’t know if it’s been done, or where to find the studies that probably have been done. I’m sure the numbers exist, but I don’t know if they’ve been crunched.

          However, given that m&m rates have been dropping since we started doing EFM, it is terribly unethical to do a randomized study which would be the ideal scientific way to figure it out. That should be obvious to you.

    • Sue

      We already know that cesarean delivery is associated with improved neonatal outcomes, at the cost of a small increase in maternal complications (mostly minor and short-lived).

      • Gatita

        Amy did a post many years ago on her old Homebirth Debate blog discussing at what the CS rate could be too high: http://homebirthdebate.blogspot.com/2008/04/c-sections-and-diminishing-returns.html. And yes, there can be a CS rate that is too high when you weigh the number of lives saved against the number of mothers who are harmed and killed by the procedure. So knowing that the more EFM = more CS, at what point do you figure that the benefits to the baby are not outweighed by the risks to the mother? And how do you figure that out from a study design/statistical POV?

        • Dr Kitty

          You’re asking very complex questions.
          On one hand, informed consent means that each woman should have all the risks/ benefits of VB vs CS laid out, as they apply to her, and should be able to decide, based on her own priorities, experiences and medical history, what she wants.
          Which means MRCS, ERCS, VBAC and refusing CS under all circumstances would ALL be acceptable outcomes of the informed consent process.

          The other question is about statistically at which point the increased risk of CS becomes acceptable for a population, when considering whether a certain screening test or intervention should become universal SOP.

          If “too many” women, on population terms, having been fully advised of all the pros and cons, prefer CS, how do you then make that fit with ideas of autonomy, beneficence and justice to reduce the rate to a statistically “acceptable” level?

  • Megan

    OT but just got the results of my first ultrasound. Baby measured perfectly with a HR of 138. I guess now that it feels more real I’m going to have to really start thinking about big decisions like RCS vs VBAC, whether to try to breastfeed or not, or whether to have the kids share a room! Like I said to my husband after the ultrasound, “sh$& just got real.” We are scared but excited!

    • Montserrat Blanco

      Congratulations!!!

    • What was the indication for the primary C/S?

      • Megan

        She was OP and asynclitic (which we suspected but found confirmed during the CS). I had needed very high doses of pitocin during my induction at 37 weeks for gestational hypertension with an AFI of only 3 (but no IUGR). I had two failed epidurals (I was walking around and could feel everything!) and got to 8 cm after days of induction but she turned and I stopped progressing and actually went back to 6cm. Since I had no pain relief options at that point and we’d been trying for so long we just decided CS was the answer at that point. So a lot of things, but mainly positioning was the biggest reason… I’m mainly considering VBAC at all because I may want more children and I have an irrational fear of placenta acreta. (See it once and you never forget….)

        • Gatita

          Oh God, look at the Wikipedia entry for asynclitic:

          https://en.m.wikipedia.org/wiki/Asynclitic_birth

          • Tiffany Aching

            The source they quote is a book by Penny Simkin, who seems to be another NCB nutjob (and she’s a physical therapist, not an OB or a CNM, of course). Here is an article of the Seattle Times about her (be warned, it is incredibly irritating http://www.seattletimes.com/pacific-nw-magazine/looking-to-nature-doula-penny-simkin-practices-the-art-of-delivery/)

          • Megan

            Oh geez. Yeah no amount of position changes would’ve helped me. Plus since she was OP and I had no functioning epidural the back labor was excruciating. I usually love Wikipedia but his is obviously very biased. I’m thankful in my situation that we finally say enough was enough and just had our cesarean.

          • Montserrat Blanco

            I am really glad it all went well in the end. I really hope you have an easier delivery this time by the method of your choosing.

          • Daleth

            The good thing about Wikipedia is if you don’t like an entry, you can fix it. 🙂

        • If the baby is OA this time, you sound like an excellent candidate for VBAC. This time you may find everything is very different, from the type of contractions onwards. Even if you do wind up with a C/S, having been through it once, it is [usually] a lot less traumatic since you half-expect it.

          Best of luck [from someone who had all three kids by C/S — no dilatation at all after 48 hours of contractions with #1]

          Remember that the incidence of true placenta accreta is rare — keep everything in proportion!

          • Megan

            My first CS was complicated by uterine atony bad enough to cause a uterine inversion after extracting my daughter and PPH requiring transfusion. I’m sure that all the pitocin was a large part of that. Also my children will only be 18 months apart so my birth-to-conception interval is only 9-10 months. I’m not sure how these things will affect my candidacy for VBAC but I plan to have a long discussion with my family doc managing my prenatal care and her OB backup (who did my first CS) about it. I imagine what I decide to do will come down to the circumstances at the end of my pregnancy. If I end up requiring another induction and I’m unfavorable I may just go RCS but if all things progress normally I may try for.VBAC. We’ll see.

          • Sounds like a sensible approach. Nothing in obstetrics is static. A plan of action at 36 weeks can be inappropriate by the time labor begins…

          • yentavegan

            May I be the yenta in the room? Go for the c/sec. A planned c/sec, ( I have had 2) are joyous and easy to recover from.

          • Megan

            I might. I haven’t decided what I’ll do yet. I do have to think also about my daughter and planning in such a way that will be easiest for her to and that may mean a planned RCS so that she is away from us the shortest amount of time and we can plan the day. Plus, if my recovery is less traumatic then that would be better for all involved. I know on other boards, I’d get ripped a new one for saying those reasons were part of my decision process but I know people are more open minded here.

          • Roadstergal

            It’s a crazy world when wanting the minimum of disruption to your daughter’s life is a selfish, irresponsible consideration. 🙁

            I’m a control freak – I love things that are scheduled. :p

          • KeeperOfTheBooks

            Preach it, sister. I’m right there with ya on those reasons for why I might go for a RCS next time, or perhaps an induction if my OB thinks it’s a good idea. I’m not anti-VBAC per se, but strictly from a practical perspective, the nearest relative able to offer much help is a plane flight away. DD has to stay with *someone*, and call me selfish, but I’d really like DH there while I’m in labor or getting a CS. Plus, DH can only take a day or two off work; can you imagine chasing a toddler two days out from either a CS or a vaginal birth while caring for a newborn, and all without help? The mind boggles.

          • Young CC Prof

            Putting convenience ahead of safety is bad. Taking convenience into consideration when choosing from a menu of reasonably safe options is a perfectly sensible thing to do.

          • Dr Kitty

            There is a reason why I have an ERCS booked 6 days before my daughter starts back to school…

            Knowing that all being well there will be no 3am call to grandparents to come and take care of my daughter, no panic about who will pick her up from daycare, no chance that she’ll wake up one morning and find both her parents have disappeared to hospital in the middle of the night, those are not small things.

            Especially since I saw how upset she was when I ended up having to go to A&E at 5am with a ruptured ovarian cyst, and the next time she saw me was when I got home after the surgery.

            Your job is to weigh up all the pros and cons and how they apply uniquely to you, then make the decision that seems best.

            If you have a kid who’ll wake up at 4am just to check if mummy is still home and hasn’t had to have another operation, or who comes into YOUR room to check on you while you sleep, the idea of an unpredictably timed labour on top of the stress of a new school year is a definite consideration.

            I’d never intended to VBAC, but these are the things that worry me about the possibility of spontaneous labour before the ERCS date.

          • Who?

            People-well, some people-will love to tell you that you should never consider convenience when making decisions. Those people are generally wearing very shiny martyr’s badges pinned to their sackcloth and ashes, so they are easy to spot and avoid.

            Good luck with the pregnancy, and best wishes for the least medically interesting delivery imaginable.

        • fiftyfifty1

          ” I have an irrational fear of placenta acreta.”

          There is no such thing as an irrational fear of placenta accreta.

          • Jessica

            A high school classmate developed placenta percreta with her fourth pregnancy. She delivered the baby last month and as I understand it was a grueling and long surgery that required a lot of blood products, but she and the baby survived. Very scary!

          • mabelcruet

            I was recently involved in a maternal death investigation as a result of placenta percreta. It was known to be be low lying and probably accreta, so an elective section carried out, but it had eroded through the cervix and vaginal vault and was crawling around the bladder and sigmoid. Mum got something like 64 units of packed cells and the same again in plasma and all the cryoprecipitates etc possible but arrestedfrom massive haemorrhage and couldn’t be resuscitated. Placentas-incredible and fascinating things, but when they go bad they go very bad.

          • Karen in SC

            Had the woman had a lot of c-sections? or just one?

          • mabelcruet

            Two previous I think. It honestly looked like a malignant tumour infiltrating all through her pelvis. Clinically they were aware that there were pgoing to be problems so it was a planned section under GA but turned out far worse than expected.

          • I am currently 34 weeks and have accreta. I am delivering next week with a planned hysterectomy. I am terrified.

          • fiftyfifty1

            Wishing you and the baby a very smooth process and an easy recovery. I’m glad they know ahead of time and everyone is prepared.

          • Gatita

            Many good wishes going out to you and your baby for a straightforward surgery and recovery.

          • Megan

            I’m sorry. I hope all goes well for you. I would be scared too. I’m just glad you and your medical team know about it in advance.

          • Thank you. And congratulations to you! In hindsight it was very rude of me to hijack your thread like this.

          • Montserrat Blanco

            Very good wishes. I hope you have an easy recovery and your baby does well. There are some moms of preemies here (myself included). If you need some tips or just to vent please do come here and post on whatever is the last post.

          • Megan

            No worries! We all need support through difficult things like that!

          • Sue

            Best wishes to you, Ginger. Of course it is terrifying in anticipation, but so much safet knowing what is going on and having it competently managed.

          • yentavegan

            I amThinking of you and sending my wishes for a safe delivery for you and your baby.

          • moto_librarian

            Hoping that all goes well! Please update us when you are able.

          • demodocus

            Good luck!

          • Thank you all so much for your kind words. I will definitely update when I can. I have been lurking here for a few months and am so glad to have found not only Dr. Tuteur’s writing but also this community of commenters.

          • Dr Kitty

            I had a patient who somehow had percreta, increta and accreta in her first pregnancy.
            She and the baby were ok thankfully, I think she ended up having large bits of placenta just left in her abdomen because they couldn’t be removed safely.

            Seeing one bad rupture was enough for me, and actually saying “I was involved in a rupture with a bad outcome as a trainee. VBAC is not for me” has actually changed the attitudes of some of the maternity staff I have encountered this time. Amazingly some have gone from being obviously judgemental to being a lot more understanding.

  • Amazed

    I saw the title and I thought, “I am counting to three before I see the unnecessarian raising its ugly head”. I made it to two.

    Fuck you, not-Dr. A c-section, even an unnecessary one, isn’t the greatest problem in the world. In fact, just a few hours ago I took a former unnecessarian baby to the first opera in her young life. And while her indignation at Turandot’s justice deficiency – “It isn’t fair, he got the answers right! Why is she still refusing to marry him?” – that she hissed in my ear might be due to some inborn lack of awareness in unecessarian babies (don’t they know that life is a bitch and opera isn’t fair?), I found it wonderful that she enjoyed it so much, that she was interested in almost everything, that she had the chance to appreciate it. Why the hell should it matter that her mom committed the greatest atrocities of all in those loonies’ book – not even trying for a healing VBAC, probably because she lacked awareness just how much she’d been injured?

    EFM is harmful? Barf. I imagine that not having a child to take to the theatre because of the lack of EFM hurts more. It just makes sense to me. But what do I know? I am not even a mother yet.

  • KarenJJ

    I came into hospital at 41 weeks with broken waters, light meconium and a baby that hadn’t descended after hours of regular contractions.. One of the first things the hospital did was use the electronic monitoring to look at my baby’s heart rate and found..

    that bub was doing fine.

    Still, I was offered the option for a c-section (or I could wait a while and see how things progressed), and despite my class in hypnobirthing and despite dedication towards having an unmedicated birth in the heat of the moment (and after 10 hours of contractions that had done nothing to progress anything apart from breaking my waters) I chose c-section. No regrets. Baby was born healthy and was a normal weight and length but had a 90th percentile head circumference. Finding hats for my kids is still an issue.

  • moto_librarian

    If this jackass had done any actual research, he might have discovered that fetal distress doesn’t always mean c-section. During my second labor, I had CEFM because I had an epidural. There were signs that our son wasn’t tolerating labor perfectly, but position changes helped. When the midwife broke my water, there was mec, so the NICU team was on hand for delivery. Severe distress started while he was crowning, and I heard the nurse ask if she needed to page the OB emergency team. Our son I rolled out of his cord, and needed deep suction, O2 via CPAP, and vigorous stimulation. He did not go to the NICU. Had I not been being monitored, there would not have been any sense of urgency about getting him delivered. Since he was crowning, I could have had a vacuum extraction or forceps if I couldn’t push him out on my own. Personally, I vastly preferred knowing that he needed to be delivered immediately!

    • Gatita

      There were signs that our son wasn’t tolerating labor perfectly, but position changes helped.

      Same here. My son’s heart rate got wonky early in labor because I was laying on my side. Position change cleared it up.

    • Allie P

      The “suffering” I did due to EFM was lying in a slightly uncomfortable position and getting an oxygen mask at one point. Talk about #firstworldproblems. Then again, I guess a safe, timely, POSSIBLY “unnecessary” c-section with a healthy baby and mother at the other end in a lovely clean, well-appointed hospital is the epitome of a first world problem.

  • demodocus

    The brave lone journalist must be right, because everybody knows about those evil, Zionist, Nazi, Reptilian Masons are out to rule the severely depopulated world. I’m just not sure why they don’t grab their ray guns.

    • Empliau

      I have Rh negative blood. I’m still waiting to be inducted into the secret reptilian overlord cabal. Failing that, Krugerrands will be accepted.

  • JellyCat

    Of course, dangerous epidurals and dangerous and traumatizing c sections. There are a lot of mothers out there traumatized by the c sectioned that saved their baby’s life. This why they want to stop EFM

  • MLE

    That piece deserves some kind of stupidity award in the NCB hall of infamy.

  • Sarah

    I must’ve missed him spending equal amounts of time attempting to find those of us who had positive experiences as a result of EFM. Very balanced journalism there, evidently going into this with the most open of minds.

    • yugaya

      Not to mention searching for stories of EFM disappointment on a web page that is a marketing tool for only type of pregnancy and birth attendants who are not qualified to use it or interpret its results. An OB can make a professional call to go without it, a CNM can make that call too, and Midwifery Today idiot CPM/LM brigades don’t have any other options and have a direct interest to feed all their clients and potential clients stories how it is perfectly ok to just be limited to what they have on offer.

      Is that what goes for investigative journalism these days?

  • Carolina

    EFM detected my daughter’s late decels during the initial phase of my induction (hadn’t even received Pitocin yet). She was out via C-section a 20 minutes later and she turns 5 on Monday. She’s smart, hilarious, and wonderful. I’m so grateful

  • jhr

    The New Republic used to be the gold standard for progressive journalism. How tragic that they have stooped to printing such material.

  • 2boyz

    My second birth was completely unmonitored. It happened too fast, I’m lucky I made it to the hospital at all. The baby was born with a low Apgar in obvious distress, though he turned out to be fine (probably because he got out so fast) and didn’t even need the NICU. But let me tell you, those first ten minutes, where they knew he wasn’t 100% but had nothing to go on other than my slightly brown water, were very scary.

    The building the piece around the preconceived story in the journalist’s head is a popular mode these days. Just look at that debacle with the Rolling Stone campus rape story. More of the same here.

    • Medwife

      He might’ve been distressed _because_ he came out so fast. Precipitous births can be a bit much for both mothers and babies. Glad everybody was ok!

  • Amy Tuteur, MD

    The problems with EFM are in some ways analagous to the problems with mammograms. Both are screening tests with high sensitivity and low specificity. In the case of mammograms, they will almost always detect breast cancer if it is present at a size large enough to see, but most of the abornomalities detected on mammograms aren’t cancer. No one is suggesting, however, that radiologists are deliberately hurting women by performing mammograms.

    The solutions are similar, too: better screening guidelines in low risk populations and better technology that has higher specificity.

  • Jessica

    I never felt so safe in my pregnancy as I did when my induction got underway: for 20 hours, I was reassured that someone was monitoring the baby’s heart rate and a problem could be addressed quickly. (Telemetry EFM was great – I could walk around or get in the jacuzzi tub while still getting continuous monitoring. Neither method was as awesome at relieving pain or speeding up labor as the epidural, though.)

    • Cobalt

      I loved EFM. I could hear my baby’s heart rate, which was, at the time, the best sound in the world. I turned the volume up so high the staff had to turn it down to talk once delivery was imminent. The belts could use some improvement, and placing the things could be less fussy, but I would howl if they took the option away.

      • Inmara

        I was the same, asking repeatedly to my husband how is baby doing during contractions. Also knowing that some midwives can be too obsessed with natural birth, he was aware that in case of decels we need to be insistent of safety and require OB to be present. Luckily, baby was like a champ until the very end. So I guess, according to NCBers I should complain that few hours lying on my side instead of kneeling totally ruined my birth experience.

    • Medwife

      Tele is the best!

  • lawyer jane

    What bugs me the most about this article is that it does nothing to actually help women figure out the best course of action. It’s just fear mongering – mansplaining childbirth to us wimmins. It seems But a good article would have fully interrogated all the studies, and would have taken into account the view that some mothers might prefer ECM and the “risk” of C-section, especially if the clinical experience of their own OB recommends it. He also does nothing to figure out whether his presumable alternative – old fashioned auscultation – is even practical in modern hospital practices, and what the unintended consequences might be of that.
    The article does nothing for a new mother but try to induce fear and paranoia of her doctor and hospitals. I’m imagining that there will be a whole crop of mothers who freak out and become full of guilt when they move from low risk to high risk during their pregnancies (e.g., meconium, induction) and are told that they need EFM.
    I really just think that Berlantsky is getting his ego stroked by the idea that he is the Savior of Women.

    • Anj Fabian

      I vote this for Best Comment.

    • Squillo

      Exactly. First, the author leaves out the key idea: that continuous EFM is probably not necessary for low-risk women. It might be great if all low-risk women had one-to-one care by nurses well-trained in IA and its interpretation, but that’s just not the case. Which leaves us with an all-or-nothing proposition.

      At homebirth or birth center births, you might (and that’s a big MIGHT, and a probably not in the U.S.) have a midwife who is well trained in administering and interpreting IA, but what can she do if it suddenly reveals something concerning? She can’t consult an expert for a second opinion, she can’t expedite a delivery with forceps or vacuum, and she certainly can’t call for a crash section. All she can do is transport to the place where those things can happen.

    • yugaya

      “But a good article would have fully interrogated all the studies”

      A good article would not quote Sartwelle, a butthurt birth injury medmal litigator whose idiotic piece was abundantly used for this article (Sartwelle makes preposterous claim that EFM has 99% false positive rate and cites himself as source of that). This is just junk science being peddled around by junk journalism.

      • lawyer jane

        I know, that was the most preposterous quote of the whole piece! I’m like, really, you can quote a DEFENSE ATTORNEY … but not talk to a single actual doctor?

        • yugaya

          Not just any defense lawyer, but one who pulls numbers right out of his own arse. Noah Berlatsky just shifted things around a little, expanded with some
          outside quotes but basically copy/pasted most of the points he makes straight from it.

          Here is the link to Sartwelle’s pile of crap: http://www.bmpllp.com/files/tps___final_efma_bridgetoo_far_10_2_12.pdf

  • The Bofa on the Sofa

    Did the article specify how EFM is “dangerous”?

    • lawyer jane

      Because it leads to the evil epidural and C-section.

      • The Bofa on the Sofa

        Does the article say that, though?

        • lawyer jane

          Yep.

          • Cobalt

            Maybe mine was broken, then. I had EFM for all my babies, and not once did the belts even try to provide anesthesia or surgery.

          • anotheramy

            Haha! This is great! I wish I could upvote this more than once.

          • The Bofa on the Sofa

            How does EFM lead to an epidural?

          • Cobalt

            The belts are so uncomfortable that you need an epidural to cope with the discomfort.

            There probably is some merit to that argument for some women though. If your baby is one that “hides” from the monitor and you end up having to hold perfectly still in an awkward position with the belt in an uncomfortable spot, that can be your “final straw” in the decision to get an epidural you might not otherwise have wanted.

            But that’s only a loser in a risk/benefit analysis if you think epidurals are inherently bad, instead of tools that can make labor more comfortable. If an epidural lets you better tolerate the monitoring that improves your baby’s outcome, I call that a win.

          • lawyer jane

            Yes – that’s what happened to me. I had to lie down to be monitored and I found that to be incredibly painful. But I needed to be monitored (induction) and I am glad that I got the epidural.

          • MaineJen

            …more uncomfortable than the contractions? Are they for real?

          • Cobalt

            Mine were- I could hardly feel my contractions unless I walked around.

            I’ve also had a lot of impact injuries to my lower back and hips. Laying on my side without being able to move is horrific, and I can’t lay with my body weight on my lower back even when I’m not pregnant. My contractions were nothing compared to that. Thankfully, most of my babies were generally easy to hear on the monitors and I could sit or lay comfortably and wait.

            We all come to the table with our own quirks. That’s why education, options and compassion are so important for making sure the tools available aren’t baselessly limited by ignorant ideology. I didn’t need an epidural, but I wouldn’t try to take it out of anyone else’s toolbox.

          • Allie P

            Contractions are just “rushes”, remember? Not painful in the slightest! That’s all in our silly woman-heads.

          • Montserrat Blanco

            I had a 28 week baby monitored. He used to made very clear he hated the monitor by kicking it, so I had to hold it for about one hour sometimes. I still preferred that to risk CP for my baby. It does not hurt. I promise.

            To be fair, my lovely son also hated it and made it very clear he considered it awful when I laid in bed slightly on top of a little of my belly. I had to lay in bed either on my back or perfectly still on my side with not even a little bit of weight on my belly. Really nice.

          • demodocus

            Mine liked to play hide and seek with the ultrasounds and heart monitors all through pregnancy. Especially the USs. He even managed to wiggle off a few times during labor. He still thinks stethescopes are *mean*. I forgot about the monitor except when they needed to readjust it.

          • fiftyfifty1

            Although this is only true if you refuse the internal monitor. If you don’t like the belts, or the belts keep losing the baby’s heart tones, there is an easy answer that solves your problem: the internal scalp monitor.Once you have that in place you can swing from the monkey bars and it won’t miss a single fetal beat. But NCB teaches you to REFUSE REFUSE REFUSE any mention of the scalp monitor.

            It’s pretty telling isn’t it? NCB advocates say that the belt monitor makes too many mistakes, and is too limiting of movement. But then it tells women to refuse the method that is more accurate and doesn’t restrict motion. Weird huh?

          • toni

            If it’s more accurate and doesn’t impede your movement at all why isn’t it the standard form of EFM?

          • fiftyfifty1

            OBs start with the belt because it is 100% non-invasive and because the majority of women tolerate it fine (for example it didn’t hurt me at all or restirct my movement at all) and it picks up the majority of normally positioned babies fine (no problem finding my baby’s heart at all). Only when this less invasive method isn’t working do the OBs recommend a scalp monitor. To place a scalp monitor you have to do a rather long internal (vaginal) exam where you screw the wire onto the baby’s scalp. That can be uncomfortable for the woman and leave a little scab on the baby’s scalp later. Also to do it the water already needs to be broken or you have to break it (AROM).

            So in short, OBs prefer to use a non-invasive technique if it is working fine rather than switch to a more invasive one (even something barely invasive like this, unlike what NCB advocates would have you believe), that’s why they don’t just jump right to the internal one.

          • Cobalt

            I’ve only ever seen it offered if the belts are giving poor quality readings and the doctor is concerned. I think it’s more expensive, too, so it has to be justified to the patient’s health insurance in some cases. I imagine the policy on offering it, and if it can be requested, can vary widely from place to place.

      • Sarah

        I bloody wish EFM had led to an epidural with my first. She was in distress and it was a marathon complex VB, but no such luck.

      • Erin

        Silly me. I thought the train of events which lead to my epidural and section went something like this:
        Waters break prior to onset of labour -> baby starts trying to headbutt his way out via my spinal cord -> dilating extremely slowly due to son’s head being too busy hitting stuff which wasn’t my cervix -> waters broken for 60ish hours and only at 5cms -> contractions now effecting balance by locking thigh muscles up -> augmentation of labour because duration of waters broken + EFM -> insane pain and unable to move anyway -> beg anesthetist to take pain away -> three hours later he managed, was so happy I forgot to be mad about the previous 2 hours 58 minutes -> Got to 10 cms, declared miracle by Midwife -> rested for 2 and a bit hours -> pushed for 2ish hours -> waters now broken for 80ish hours and baby still too happy headbutting stuff to descend -> blood pressure nose dived -> c-section. Now however I realise that had I refused the EFM he would have somehow have managed to un-stick himself from my pelvis and cascaded forth in a beautiful natural and empowering fashion.. or not.

  • Tiffany Aching

    I am a journalist and I’m sorry to say that many of my colleagues work exactly that way (ie building a piece to “demonstrate” their opinion on a subject). Essentially it is caused by the arrogance of our profession (many journalists tend to confound cause and effect and think that they inform people because they inherently know best) and by the lack of scientific culture among journalists (many of whose studied history or literature). They do not see when their reasoning is flawed because they don’t have the tools to do so.

    Edit : Also, writing an article about how the authority figures are wrong is sexy, and many journalists think they are doing something extraordinarily investigative when they do something like that, and that it is the ultimate goal of their profession.

    • Gatita

      Did you see his responses to Amy in the comments of the article? Extremely unprofessional.

      • Tiffany Aching

        Yes, he behaves just like he were on a forum – not at all like a professional justifying his work.

  • lawyer jane

    I just perused Berlatsky’s other writings online. It seems to me that he tries to define himself by trying to belong to the club of internet feminism – and he mistakenly believes that all ladies on the internet believe in breastfeeding and natural childbirth. The fact that there are a lot of us who embrace modern medicine and freedom from breastfeeding has thrown him for a loop; he’s having a hard time processing the fact that we don’t define ourselves by our breasts & vaginas.

  • Amy Tuteur, MD

    I know that it would really drive the NCB folks around the bend, but what we need is more advanced technology than EFM. What we really want to know is whether the fetus is getting enough oxygen. We have a non-invasive way to monitor oxygen in babies, children and adults: the O2 sat monitors, those small devices they clip over finger nail that can detect oxygen concentration in the nail bed. The goal would be to develop something similar for babies. That kind of screening test has both high sensitivity and high specificity.

    A intrauterine monitor has been developed that is designed to measure oxygen concentration through the fetal skin and can be inserted into the uterus during labor. Unfortunately, although it was great in theory, it hasn’t worked in practice. It also seems to interfere with labor, so it’s back to the drawing board.

    • Amy M

      They put that clip on one of my babies during labor, and monitored the other externally. The one with the clip started showing distress signs at one point, so they pulled him out with the vaccuum. Why is the internal clip not so great, and what do you think could be done to improve it?

      • Amy Tuteur, MD

        The clip is actually quite reliable.

        • Amy M

          So maybe I’m not understanding, what’s the difference between that scalp clip monitor and the internal IU device you mention above?

          • noemi

            The fetal scalp clip currently used monitors the fetal heart rate more closely. The clip that Dr. T is referring to is theoretical. There is no clip that has the capacity to monitor fetal oxygenation. There may be some in development but none are used currently.

          • Amy M

            Oh I see! Thanks, I was mixing up just the heart rate monitor, with the actual O2 monitor.

        • Sarah

          It never stayed on for long in either of my labours.

    • lawyer jane

      But do we even know if the fetal brain is the same when it comes to O2? It would make sense that the fetal brain can handle temporary deprivation during labor.
      But in any event, having seen how hard severe cerebral palsy can be, I would have my baby by C-section to prevent 1/1000 babies from having CP. But I am not sure other people think this way.

      • Roadstergal

        “I would have my baby by C-section to prevent 1/1000 babies from having CP.”

        That’s the difficult part. When it comes to your own baby, you’re looking at a 1/1000 risk and deciding if you want to take it. When you look at the population, it gets spun as 999 women ‘taking one for the team.’ But it’s the individual risk that each woman faces, and the post hoc decision of how many were ‘unnecessary’ is about improving practice going forward, not about second-guessing the risk reduction that was done with the best data at the time!

        • lawyer jane

          Yes, it’s about my own risk. But it’s also a sort of prisoner’s dilemma – I’m happy to submit to this over-sensitive technology EVEN IF it leads to an “unnecessary C-section” because it might prevent someone else’s baby from getting cerebral palsy or dying. The only way the system works is if we all agree that all low-risk women should get EFM — otherwise I won’t get it. It is very similar to mammograms – I’m happy to submit to an “unneeded” biopsy because a routine mammogram ended up actually saving a good friend’s life.

          • Cobalt

            “The only way the system works is if we all agree that all low-risk women should get EFM — otherwise I won’t get it.”

            This is a very important bit of parsing. Letting NCB advocates dictate general protocols will result in a lot of women losing a lot of options. There are campaigns against OB care, anesthesia, formula access, nurseries, ultrasounds, and even hospital birth in general.

  • EmbraceYourInnerCrone

    Useless? I don’t think my kid would consider it useless. I went into labor and was progressing quickly and normally. They got the EFM on me and for a few hours things were fine. Then somethings started to show up that indicated the baby was in distress. she went to consult the OB. They asked me if I was ok with them putting the internal scalp monitor on the baby. They broke my water, it was meconium stained and the internal monitor indicated the baby was not tolerating contractions well at all. I was asked if I was ok with them doing an episiotomy and using the vaccum to get her out quick. They also called the NICU team up to the delivery room at this time. In conclusion, my daughter was got out fast, suctioned by the nicu experts, checked out by the on-call neonatologist and pronounced fine. What would have happened if they had just let “nature” take its course. I honestly don’t know and I don’t want to know. A situation that could have ended in her death or in her suffering oxygen deprivation ended with a healthy baby with no brain damage. And yes I had some discomfort, an episiotomy, and stitches. For my daughter to be born healthy I’ll take it.

    • Montserrat Blanco

      I am really glad your daughter did well. And yes, I think that she will not consider EFM useless or dangerous.

  • Amy M

    The people who demonize EFM because it “causes unnecessary Csections” seem to be saying “well, if we don’t know there’s a problem, we don’t have to fix it.” But I think the number of women who truly would be ok with having an intrapartum death that could have been prevented by Csection are few. I mean, let’s say an NCB woman (one who wants an unmedicated, vaginal birth with as little intervention as possible) is laboring in the hospital, being monitored. Then an alarm sounds and the doctor suggests that a Csection might be in order. If the woman REALLY doesn’t want a Csection, she can decide to not consent. My impression is that almost never happens, no matter how upset the woman is afterwards. She won’t take that risk for her baby. Women who really, really, really will do anything to avoid a Csection will just stay home anyway. I guess its easier to deal with a death if you can claim ignorance of prior distress, than if you know there might have been a problem, but you chose to ignore it.

    • Roadstergal

      “She won’t take that risk for her baby.”
      NCB translation – “She was pressured into a C-section by playing the Dead Baby Card.”

      • Amy M

        Yep. But still—very few put their money where their mouths are, when their own children are involved. If they really believe that EFM-signalled Csections are 99% unnecessary, they can choose to believe they are in that 99% and avoid it. Most don’t want to risk being in that 1%, no matter how remote the chance of disaster.

    • Cobalt

      I am totally willing to concede that EFM causes unnecessary cesareans, because it’s true. There are false positives. What Berlatsky and NCB advocates are missing is that those unnecessary cesareans are caused by the exact same information and criteria that causes very necessary cesareans. If we start changing the criteria to reduce the cesarean rate, preventable perinatal injuries and deaths will occur.

      • Roadstergal

        Is a C-section unnecessary if you can’t tell that it was? Yes, we know there are false positives – but do we know, even in retrospect, which ones were false positives? It’s just an percentage estimate, isn’t it?
        This is Schrödinger’s Uterus.

        • Cobalt

          I don’t know how reliably a false positive can be retroactively diagnosed, and how much that reliability can fluctuate based on circumstances. I know a lot of true positives can be, and the rate of known true positives can be compared to the morbidity and mortality rates of different criteria and cesarean rates, and you can get a range that shows how many lives are saved per how many cesareans at different cesarean rates.

          We know false positives happen (but we can’t tell if they are happening to a specific individual at a given time). With current technology the only way to prevent them is to either not monitor or not act (change the reaction criteria). Unfortunately, this will result in preventable damage and death.

          A better solution would be to eliminate false positives through more sensitive technology so our reaction criteria could be refined (instead of dulled) to reduce unnecessary and unwanted procedures.

          • Roadstergal

            Agree with all of that. Except that the problem with EFM seems not to be the sensitivity, but the specificity?
            I’m very interested in this subject because I work on biomarkers, and maybe a quarter of that work is in Dx development, and sensitivity/specificity/cutoffs are a lot of that. You’ll have a beautifully sensitive assay… that’s just not specific enough. You can make it more specific by raising the cutoff, and then you lose that beautiful specificity. So what can you add to it to maximize the specificity? That’s the challenge.

          • Cobalt

            It’s a limitation of only measuring one metric-heart rate. The metrics for HR are probably as fine tuned as they can reasonably get. If you could add other metrics to exclude the variations in HR that look like trouble but aren’t, you’d be building a better test. The details on how to do that are beyond me, but I’m sure there’s a lab working on it.

        • Allie P

          Schrödinger’s Uterus! I love it! Unnecessary c-sections are like unnecessary seatbelts. Who cares? I don’t get out of my car after every drive and go, “Well, that was an annoyance it turns out I shouldn’t have had to deal with!” Once we get those pre-cogs in, we’ll be able to ascertain which c-sections are “necessary” (NCB code for — the baby was a breath away from dying if we didn’t cut it out!) and which ones the stupid lady should just suck it up and push, lazy woman, punishment of Eve, yadda yadda.

      • Montserrat Blanco

        Of course! But please, monitor my labor! I prefer a CS than a slight increase in CP for my baby. I know, I know, I am silly but still…

    • Mel

      Unfortunately, I know of two situations exactly like you described above where the woman refused. The staff begged and pleaded. She refused. The babies in both cases suffocated. The moms got the vaginal birth they wanted – just not the healthy baby NCB promised.

      • Roadstergal

        It makes me think of that woman whose brave “refused a C-section” story was all over my Facebook – the one whose baby had an NICU stay and she had a massive PPH, all in order to have the VB that she knew was ‘safer for her and her baby.’ I just don’t get that headspace.

        • The Bofa on the Sofa

          What was Dr Amy’s analogy? I drove home drunk and it was all great. Oh sure, I ran over the garbage cans and backed over the kids’ bikes, but see how great I did?

      • Kelly

        That is awful. I don’t want their children to suffer or die but it does show that the doctors actually do know what they are doing.

  • superhappycamper

    How come NCB folks never acknowledge that many babies are most likely “fine” BECAUSE of monitoring, instead of damaged or dead? It may not be a precise tool but it’s what we have now. Will they only accept that things like monitoring and c sections are “necessary” if a baby is born with an Apgar score that is “low enough”? I really don’t get this.

    • Angharad

      This is a great point! My daughter had significant heart rate deceleration during labor, so I had an episiotomy and she was delivered instrumentally. She was purple from head to toe, but she was just fine by one minute. If we hadn’t been monitoring her and I had continued to push for longer, who knows what could have happened?

      • Melanie

        Duh she would have been perfect and organic and healthy. She was only purple because the vacuum sucked off her aura, you should have left her because babies know when to be born

    • Roadstergal

      To continue the line of thought below, it’s like saying, “I was in a car crash and was wearing my seatbelt, and I walked away unharmed. Clearly, the seatbelt was unnecessary.”

    • Allie P

      Yes, that is EXACTLY what they think. Hang out on any NCB forum, and you’ll see people being taught that their CS were “unnecessary” because their babies didn’t require NICU stays or didn’t need resuscitation or other post-birth medical interventions. “Oh, look, he was fine all along, and now I have this surgery to recover from!” seems to be the common refrain.

  • Roadstergal

    I’m interested in hearing from women who have had negative experiences with seatbelts. For example, if seatbelts turned out to be unnecessarily restrictive or painful on a given drive, or also if seatbelts lead the occupants to believe they would be unharmed in a crash and they weren’t…

    • Angharad

      You could probably even find someone who was, for example, internally bruised or trapped in a car by their seatbelt during a bad accident.

      • Roadstergal

        The energies involved in a car crash can be massive, and life-saving restraints can indeed cause injuries:
        http://www.ncbi.nlm.nih.gov/pubmed/25887833
        The sensible thing to do is to continue to work to refine these restraints, rather than avoiding them altogether.

        • Angharad

          Or we could trust cars! People have been getting from point A to point B for thousands of years without restraints. Even my grandmother rode in cars without seatbelts. Clearly they’re not necessary or the human race wouldn’t be here today.

      • Kelly

        People do die because of a car seat. It just saves way more lives than it kills. To me, it is the same as vaccines.

      • Mel

        My husband was temporarily trapped by his seat belt when his truck rolled over into a snowbank a few winters ago. It held him in his seat upside down.

        This most likely saved his life, so he’s not too upset about it.

      • Seatbelts even (very rarely) lead to otherwise avoidable deaths! I know that if you are very thin, a seatbelt can actually bisect your liver which is, of course, very bad.

        But! The chances of that happening are minute compared to the chances of it saving your life in a myriad of other ways.

    • FortyMegabytes

      I was in a serious car accident once as a kid, where the last image I remember is the car door crumpling inwards towards me before I blacked out, and the *only* damage I took was from the seatbelt knocking the wind out of me. My next memory was of me on my hands and knees, gasping for breath.

      I totally blame seatbelts for this. I walked away from the car accident scarred forever with the memory of being out of breath for a few seconds. I’ve had to live with that for almost 40 years now.

      Yeah, the driver of my car, who wasn’t wearing a seatbelt, suffered a severe concussion, but that doesn’t mean anything. Concussions can happen to anyone. Nature made our skulls thick for a reason; trust in it.

      • Roadstergal

        Kale is high in calcium. If the driver had been eating plenty of it in anticipation of the trip, said skull would have been thick and strong enough to avoid injury.

        • MLE

          Is that why nothing gets through their thick NCB heads?

          • Amazed

            That must be it.

            We have a stake joke about the old regime here. How do you boil a Communist’s head? Why, you just put it into a saucepan, hold it in place with a big stone and you boil it until the stone goes soft!

            Same thing here. Even the near or not near death of their very own babies cannot go through. Their stones must have gone to mush by now. I cannot even.

            And the so-caled journalist like the cartoon character from the article aren’t helping.

  • Mel

    Personally, I prefer being alive with CP – which may have happened before labor, during labor or when I was a preemie who wasn’t so good at that whole breathing thing – than being dead.

    That’s the part that boggles my mind. People never seem to get that the correct control group isn’t that baby in the next bassinet who popped out easily compared to your CS-baby who had persistent heart deceleration; it’s the baby who was born nearly dead or dead into the midwife’s hands in the absence of heart monitoring.

  • Mel

    My husband is alive today because of EFM. His mom had two choices of local hospitals to deliver in and her OB recommended the one that had EFM. His mom had had a really easy labor and was approaching transition when my husband’s heart rate dropped. My father-in-law says he was never as scared as he was when he ran out into the hallway and started screaming for help because he and my mother-in-law could watch the baby’s heart-rate plummeting.

    An OB, and a crack team of nurses came in and delivered Nico in record time. His heart rate was in the 30’s. His umbilical cord was wrapped around his neck three times tightly. Apparently, when he dropped to a certain station, the umbilical pulled tight and started to choke him to death. His head was purple and his body was grey when he was delivered. Thanks to a peds team, he was screaming and pink within 5 minutes.

    So, yeah. EFM all the way.

    • Megan

      Yeah I had one decel during my entire 5 day induction/labor with my daughter. It was when my blood pressure dropped very low after my epidural. It was the scariest moment of the entire experience, not when they said to me, “OK, you have tried everything possible to get this baby out and she appears to be OP. We recommend Csection.”

    • swbarnes2

      Another little point for modern EFM; at my hospital, the EMF for all the patients was up on a screen in the nurse’s station. So when my kid’s heart rate dropped as they were putting the Foley catheter in (a common occurrence, apparently) 4 nurses ran in to help turn me on my side. No one needed to yell down the hall for more help.

  • FortyMegabytes

    Brilliant takedown, Dr. Tuteur. Hopefully this nips this in the bud.

    Sadly, it probably won’t.