It made intuitive sense that it would improve outcomes for babies. In fact, it made so much sense that it was implemented before large scale testing was conducted. Now, years later, it turns out that the benefits were dramatically overstated and the risks were ignored.
I could be talking about electronic fetal monitoring (EFM) that both monitors and records the fetal heart rate during labor. It made intuitive sense that it would improve outcomes for babies because the all too common phenomenon of stillbirth was preceded by abnormal fetal heart rate patterns. Once the equipment became available it was rushed into clinical practice rather than wait for large scale studies to prove its benefits. Now, decades later, we find that the impact on neonatal health is far less that we predicted and the side effects — particularly a dramatically increased rate of C-section for fetal distress — are far greater than we ever imagined.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Professional lactivists should learn from the mistakes of obstetricians. Just because something has intuitive appeal for improving outcomes doesn’t mean that it will.[/pullquote]
But I’m not talking about EFM; I’m talking about breastfeeding.
It made intuitive sense that breastfeeding would improve outcomes for babies because it had evolved to become the natural food for babies. In the wake of the Nestle debacle of the 1970’s, when African mothers were convinced to switch from breastfeeding to formula and their babies died as a result of the contaminated water used to prepare it, aggressive promotion of breastfeeding was rushed into clinical practice rather than wait for large scale studies to prove its benefits. Now, decades later, we find that the impact on neonatal health of term babies is nearly non-existent (though it is beneficial for preemies) and the side effects — including a doubling of neonatal hospital readmissions, an increase in neonatal hypernatremic dehydration and jaundice induced brain damage, and an epidemic of newborns dying in the hospital after being smothered in mothers’ beds or injured falling out of them — are far greater than we ever imagined.
The benefits of breastfeeding keep shrinking.
Consider the new paper from Kramer et al. on the latest results from the PROBIT study, Breastfeeding during infancy and neurocognitive function in adolescence: 16-year follow-up of the PROBIT cluster-randomized trial:
A total of 13,557 participants (79.5% of the 17,046 randomized) of the Promotion of Breastfeeding Intervention Trial (PROBIT) were followed up at age 16 from September 2012 to July 2015. At the follow-up, neurocognitive function was assessed in 7 verbal and nonverbal cognitive domains using a computerized, self-administered test battery …
We observed no benefit of a breastfeeding promotion intervention on overall neurocognitive function…
This is big news because the PROBIT studies were among the first to claim neurocognitive benefits from breastfeeding. But it is not surprising news since the Colen study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons, demonstrated that nearly every puported benefits of breastfeeding disappeared when researchers corrected for maternal socio-economic status.
What should we do when we find that our intuitive sense of benefit is not supported by the scientific evidence?
In the case of electronic fetal monitoring, we are stuck between a rock and a hard place. Research shows that EFM has a high false positive rate meaning that it suggests fetal distress in many cases where the baby is not distressed. On the other hand, when the baby is distressed, it will be accurately reflected in the heart rate tracing and should be acted upon; so it does have important clinical utility. Moreover, though we understand the limitations of EFM, we have nothing yet with which to replace it. We continue using it despite its limitations because it does have significant benefits that outweigh the risks. In the meantime, ongoing research is looking for more reliable ways of monitoring babies in labor.
In the case of breastfeeding, we are not stuck at all. We have infant formula, an excellent form of nutrition for babies that has been shown over multiple generations and tens of millions of babies to produce healthy offspring indistinguishable from those who were breastfed. In fact, despite mathematical models claiming that lives and money are saved when breastfeeding rates increase, professional lactivists are unable to point to any lives of term babies or money saved as the breastfeeding rate has triple over the past 40 years.
What do breastfeeding and electronic fetal monitoring have in common? Both have failed to produce the benefits predicted; both have serious risks, and both are in need of revision.
We’ve stopped overstating the benefits of EFM and we should stop overstating the benefits of breastfeeding.
We are working assiduously to reduce the risks of EFM and we should be working assiduously to reduce the risks of breastfeeding.
We’re looking for a substitute for EFM that has the same advantages without the unfortunate side effects. We already have a substitute for breastfeeding that has nearly all the same advantages without the unfortunate side effects. It’s called formula and instead of demonizing it, we should be promoting its use when needed or wanted.
Professional lactivists should learn from the mistakes of obstetricians. Just because something has intuitive appeal for improving outcomes doesn’t mean that it will. And when it doesn’t, we should reassess our claims instead of doubling down on them.
EFM does exactly what it is supposed to do when used and interpreted in the proper context as a screening test. It does not have a high false positive rate. It has poor positive predictive value. There is a difference. In reality, it doesnt teally have a “positive rate” of any type, except maybe in the most extreme FHR strip presentations, which account for 1% or less of frankly moribund fetal strip patterns. The increased cearean and intervention rates that we see are largely due to gross misinterpretation of strip patterns, by practitioners trying to use EFM as a diagnostic rather than as a screening tool.
Steven, to answer your question broadly, there are data regarding RFM use vs nothing. I believe the study was authored by Chen et al, and it looked at at use of EFM in labor vs nothing. The EFM group had significantly lower rates of perinatal and neonatal mortality compared to nothing.
You have to keep in mind that the data are somewhat poor with regard to EFM vs intermittent auscultation. There are 12 or so historical RCT’s that are fraught with poor end points, not enough statistical power. Remember, when these studies were designed, mostly in the 70’s and 80’s, no one had a flipping clue what they were looking at with regard to interpretation. They were looking at end points presuming some diagnostic positive predictive value with EFM. Babies started having decels, mom was delivered by stat cesarean, and lo and behold, baby came out…….crying and screaming???
If you want real world data and some verification of my assertion that most practitioners dont know what thay are looking at with EFM, check out the houses and cars of malpractice attorneys. Its not the EFM. Its not IA. Its the 99%+ of practitioners that are clueless. And its not their fault. They just simply dont know that they dont know. My partner and I were at a state perinatal legislative meeting last year. There were several hundred practitioners from our state in attendance. Haywood Brown, the President of the ACOG, was giving a lecture on safety and risk mitigation. He asked the crowd how many of us were EFM certified. My partner and I were the only ones to raise our hands. He then asked why the f—k every single hand didnt go up?
I lovvvvvve EFM vs IA soapboxers at meetings. It gives me some degree of pleasure to be able to just ask basic questions like what is the definition of FHR baseline? What is the definition of variability. 10 times out of 10, they dont know the answers to these stupidly basic questions about EFM, but they want to rant about “the lierature” under the pretense tgat they are some type of expert. These are the type of people that say “the data is”. More importantly though, it gives me the opportunity to encourage these colleagues to get educated and get certified, for their own sakes but much more so for the sakes of the mothers and babies.
You say that increased CS and intervention rates are mainly due to gross misinterpretation of strips, and that getting EFM certified is the solution. So what do the data show? Do EFM-certified docs have lower CS and intervention rates then? Because if a simple course can reverse the worldwide trend of rising CS rates, it is amazing to me that such a step has been overlooked.
No data regarding this unfortunately. But keep in mind that the “studies” that everyone likes to cite really suffer from this major flaw. No ome knew a flip about what they were looking at. There is absolutely no way anyone can correlate observer knowledge or understanding of EFM interpretation as a confounder.
Now, anecdotally speaking, I do have some degree of insight. As a nationally certified EFM expert, I do a fair deal of chart reviews refarding EFM related issues. What I have found consistently is that yhere seems to be a distinct polar opposite dichotomy with regard to lack of understanding when it comes to EFM. On one hand, you have the patient who gets cut prematurely without even the slightest attempt to correct any decel patterns. These are the patients who are having decels but still have moderate variability and/ or accels. Then on the other hand, you have the oatients who get cut too late, and baby crosses injury threshold or even dies. The strip is persistently abnormal and it gets watched with the hope it will get better or it is simply misinterpreted, and baby runs out of reserve and the stat cesarean at that point is too late to avoid metabolic acidemia. Both if these extremes come from lack of understanding. A sort of cognitive dissonance if you will. The worst part is that these practitioners don’t know that they don’t know.
EFM is a tool. Just like any tool, you have to know how to use it. Understanding EFM is si much more than just looking at a strip. It’s about understanding patterns, understanding maternal fetal oxygenation pathways, understanding fetal physiology, understanding the equipment used, understanding the medico-legal aspects. The kiss of death for any practitioner sitting facing a jury is getting hammered by a lawyer, who WILL know more about EFM than you, asking you questions about all of those above issues and you not knowing the answers. All of your credibility in the courtroom is lost in that moment. It comes down to 3 basic tenets: What does it look like? What does it MEAN? What do you do about it?
It’s not about having data regarding EFM certified vs non certified practitioners. It’s about everyone that delivers babies should just be EFM certified. End of story. It’s the prudent thing to do. Again, we get these yahoos that spout off on the literature, and they get shit down by simply asking “what is the definition of FHR baseline?”. This is my go to question in malpractice cases involving injured or dead babies, right after the question “Would you consider yourself an expert in EFM as part of your job?” is asked. It’s all downhill from there for that poor soul on the witness stand after that one simple question. As it should be. Those parents deserved better.
Sorry for the typos! My thumb is too big. Unfortunately, I am not typing certified! Lol
Meant to write “get shot down”. Facepalming….
“It’s not about having data regarding EFM certified vs non certified practitioners. It’s about that everyone that delivers babies should just be EFM certified. End of story.”
Being EFM-certified does sound intuitively good, but the whole point of the original post is that what sounds intuitively good may not actually improve outcomes, and may even worsen them. I understand that you, as an EFM expert trainer, wholeheartedly believe that universal EFM certification will reverse the rising CS trend while at the same time giving better outcomes, but it sounds as if nobody has data. It’s such evidence that would make it be end of story for me.
Where do you work that so many physicians are so poorly trained? Where’s the evidence that obstetricians don’t know how to interpret EFM? Where’s the evidence that credentialing makes a difference for obstetricians?
Sure, EFM certification sounds like a reasonable idea, and it would probably be ideal if HCPs who routinely use EFM were all certified in its interpretation, at least for the sake of standardization. But like all certification exams, it consists of a finite amount of info tested in a finite number of ways. I took and passed the NCC C-EFM exam as an ob/gyn intern 3 months into residency. I read Mosby’s, did a practice test, took the exam and scored “above average” on some of the categories. I’m now certified and yet I would be foolish to think that my knowledge and skills are adequate. Strips in real life don’t fit into the neat testing scenarios and answer choices. Just like no one would argue that standardized exams required to become a physician (USMLE 1-3) are not necessary to demonstrate minimum competency, no one would consider them adequate.
EFM guy, you seem to have a wealth of technical knowledge about this. How would you boil down what you know about EFT into advice or education for the layperson/expectant mother?
Prosthetic legs can go faster than anotomical legs. Should we all get them as well? You cannot take just one outcome and use that as the basis for assessment. Intelligence is only one measure of success. There is ample evidence that breast milk and the breastfeeding relationship, when successful, is healthier for babies and mothers. Furthermore so called ‘dangers’ of breastfeeding mentioned have more to do with unfriendly environments for baby than breastfeeding. I wouldn’t normally engage a professional contrarian but spreading such misinformation is incredibly ignorant.
Do tell about the ‘ample evidence’ to which you refer, and elucidate on the meaning of ‘when successful’ as used by you.
I don’t have the time or the inclination to collate individual journal articles for an anonymous troll, however if you refer to WHO and UNICEF guidelines you will be able to find the information in the references. There are both physiological and societal reasons that breastfeeding relationships may not be successfully developed. In a society that fails to support mothers we certainly shouldn’t judge, however, they should be able to make an informed decision.
She flounced and did a dirty delete. Asking for evidence was just too much.
Well that was alarmingly easy.
How do you know monitoring has a high false positive rate? Do you compare birth outcomes for women who refused monitoring or is there a way a doctor can tell during a c-section?
I’m not sure if this is exactly what Dr. Amy is talking about but until fairly recently one of the benefits of EFM was expected lower rates of cerebral palsy. The rationale was that delivering babies before they had suffered prolonged hypoxia would drop rates of CP.
Follow-up studies have shown that EFM has not done much to change the rates of CP because most cases of CP aren’t caused by prolonged hypoxia during labor.
What I can’t remember is if intermittent monitoring of low risk women has the same effect on neonatal mortality as cEFM.
The other bit I thought of in the middle of the night was that proving a preventative measure works is harder than it seems. Oh, statistically, it’s just a matter of comparing rates prior to the intervention to rates after the intervention – but in terms of helping people understand why the intervention is important most people are not particularly in tune to statistics.
The example I learned about is using birth control measures from the 1970s. Quantifying the number of pregnancies prevented is simple math. Explaining to skeptical people who have just been introduced to birth control the number of babies that were not born is hard to do. After all, women don’t always get pregnant even when not on birth control.
Applying that to C-sections for fetal distress on EFM, doing a prompt C-section when fetal distress signs are present ends up with a robust, healthy, screaming infant. Depending on how your brain is wired, the parent may think “Whew, we missed something bad!” or “Hey, that kid was doing fine – why did I need major abdominal surgery?” The best solution that researchers have found is to talk, talk, talk about what happened before the preventative measure was available – from doctors sometimes, but usually people are most receptive to information from people who are viewed as being in the same social class and status as them. That’s where informed and chatty nurses, health care aides, teenage moms, aunts, grandmothers, elderly ladies at the grocery store etc., come into play.
I had a c-section due to one twin showing heart decels on the monitor. And boy did she come out screaming. She ended up being the healthier of the two (more lung maturity). But I don’t regret the c-section for an instant because she *might have been* in distress, using the best measures we had available.
“EFM has a high false positive rate meaning that it suggests fetal distress in many cases where the baby is not distressed.”
Is this exactly true? I mean I was taught that at least in the case of late decels it did mean fetal distress, it’s just that we can’t predict the severity of distress or predict how long the fetus can tolerate the distress without bad outcomes (loss of brain cells or worst case death.)
I forget the details but doesn’t it depend on the category? There is I, II, and III. I is normal, III is bad (like recurrent late decels) and has a better PPV. What I learned was that II is everything in between and has the highest false positive rate.
Repetitive late decelerations is a sign of fetal distress, but the baby is often quite compromised at that point. There are many other signs of distress (decreased variability, tachycardia, bradycardia, etc.) and they may be intermittent, making a strip difficult to interpret.
No, they’re not. Late decelerations are a normal physiologic response of baby to transient interruptions of the maternal fetal oxygenation pathway, at one of more points. While certain EFM patterns may potentially signal a high probability of development of fetal metabolic acidemia, the notion that one can definitively identify fetal compromise at a specific point in time with EFM is simply not true. And the majority of babies delivered do perfectly fine in the setting of recurrent late, or variable decels for that matter. As a point, variables and lates mean the exact same thing: normal fetal physiologic response to transient interruption in the maternal fetal oxygenation pathway. Different physiologic mechanisms in the fetus which cause the specific decel pattern, but both mean the same thing: transient interruption in oxygenation pathway.
There is a physiologic continuum to fetal injury. It’s not decels and then BAM!!! Baby is injured! You first need sustained hypoxemia which first leads to respiratory acidemia. Then it progresses to tissue hypoxia and anaerobic metabolism. Then comes tissue metabolic acidosis. Then comes metabolic acidemia. Then comes fetal injury once the irreversible theshold is crossed. Most babies that are frankly metabolically acidemic at birth actually bounce back quickly and are fairly normal by 5 minute APGAR. Hope this helps!
LOL…Dr. Amy, care to weigh in?
Our standard for what is acceptable in terms of delivering a healthy baby goes well beyond “the majority.”
And when it comes to my babies life and health, just knowing that “the majority turn out fine” is NOT sufficient for me.
What’s the acceptable risk? You could say that 95% of them turn out fine, and that is absolutely a majority, but 5% of a risk is still way too high. Considering the consequences of a c-section are on the whole pretty negligible, we err on the side of caution.
Would it be better if we had fewer false positives? Absolutely. And there are people working all the time to try to improve the system to try to develop better screening methods. But until they do, we have to use the methods we have that indicate risk.
As many doctors have noted, they don’t get sued for doing a c-section. They get sued for the c-section not done, or not done in time. Because we, as a society, recognize that a c-section is a safe and effective way to deliver a baby alive.
Your comment is full of “most babies …” Sorry, “most babies” don’t cut it. We want to save all babies, or at least as many as we can. We don’t sacrifice babies at the altar of natural childbirth.
There are technically no false positives with EFM. This is a difficult concept to wrap a brain around. There are really only negatives and lack of negatives. Lack of negative does not equal false positive. It only means lack of negative.
And doctors do get sued for cesareans. Injuries to both mom and baby happen during cesareans. And cesareans deemed inappropriately and unnessecarily done with regard to clinical indication is also malpractice. Another tough concept to wrap a brain around.
What’s the ratio of malpractice suits for failure to do a C-section vs unnecessary C-section? 100 to 1? 1000 to 1? Higher?
I’ve only heard of ONE malpractice suit for unnecessary c-section. My guess is the ratio is along the lines of a million to one.
You’re not telling us anything we don’t know. We know decelerations aren’t necessarily a sign of a problem, only that they *can* be. It’s not as “tough” as you’re making it out to be.
Getting sued for messing up a c-section certainly happens. What doesn’t happen is getting sued for doing a c-section “unnecessarily.” Contrast that for getting sued for NOT doing a c-section, which happens all the time.
And the relevance to clinical care is …?
There is a physiologic continuum to fetal injury. It’s not decels and then BAM!!! Baby is injured! You first need sustained hypoxemia which first leads to respiratory acidemia…
True… BUT… we have no way in real time to know for sure whether that is happening. With current technology all we can see, during labor, is the decels. If it keeps happening or if the tracing is particularly alarming, we tell the mom, “Your baby might be in danger”–because that’s true. A baby who’s not in danger won’t have them. A baby who is in danger will have them. And some babies who aren’t in danger will have them.
That’s where the mom has to decide how much of a risk she’s willing to take. It sounds, from your post, like you think moms should have a high tolerance for risk and should keep on pushing (no pun intended) for a natural birth, until more and more danger signs accumulate.
If moms follow your advice, we’ll end up with more vaginal births, but also more traumatic and completely unnecessary crash c-sections, neonatal resuscitations, and deaths. Why go that route?
That is just not true if I am reading your response in the proper context. A baby who’s not in danger won’t have them? What is “them”? Decels? Again, simply not true. And again, most babies with decels are perfectly fine. Decels happen. Labor causes transient hypoxemia. Baby is well equipped physiogically to deal with this quite swimingly. Mother Nature knows this and built fetuses this way for that reason. There is a reason why fetuses are designed to withstand prolonged periods of hypoxemia.
With the current technology, we see MUCH more than the decels. We see baseline, variability, accels, uterine activity, changes in strip trends over time, etc. Again, late, variable, and prolonged decels are normal physiologic responses to transient interruptions in the maternal fetal oxygenation pathway. A strip can have recurrent decels but also exhibit moderate variability and/or accels, and we would be reasonably assured that at THAT moment in time that we are observing the findings, fetal metabolic acidemia would be reliably excluded. Inversely, a strip with persistent absent/ minimal variability, even without any decels, has no negative predictive value and the possibility of an evolving metabolic acidemia could not be excluded. This is assuming there are no accels either. Persistent absent/minimal variability seems to be more predictive of increased risk in the development of metabolic acidemia than decels alone. The notion that no decels=ok baby is just patently incorrect and it is this type of cognitive dissonance that leads to injury. This is the disconnect. “Oh, baby is just asleep”. Or “It’s from that dose of Stadol”, that the patient got 6 hours ago and has long since worn off. Practitioners watch these strips, normalizing the abnormal through dissonance, hoping they’ll get better, and then paint themselves into a teensy weensy little corner.
Everyone with their replies seems to be misinterpreting what I am saying. I am not saying push for vaginal deliveries at all costs. I am saying that a clear understanding of EFM and fetal oxygenation and acid-base physiology will allow one to make better clinical judgements and allow for conscientious corrective actions instead of knee jerk premature cesareans, or ones that are too late. The purpose of EFM is not to allow for prompt cesarean deliveries. Barring an absolute crash emergency loke a uterine rupture or placental abruption, it’s to allow for prompt ASSESSMENT OF THE MATERNAL FETAL OXYGENATION PATHWAY AND TO INITIATE APPROPRIATE CORRECTIVE ACTIONS, which if are not succesful and the lack of negative predictive value persists remote from delivery, then an appropriate decision regarding cesrean can be made. It’s not “your baby might be in danger mom. What do you want to do?”. It’s “your baby might be in danger mom. These are the steps we’re going to take to assess the possible source, try to fix it, and if it doesn’t work within the next X amount of minutes, this is what we’re going to do to make sure we deliver a healthy baby”.
I’m not pulling this out of a hat guys. These aren’t my clinical recommendations or guidelines. These management algorithmms are expert consencus by the gurus in the ivory towers; Clark, Hankins, Miller, etc. The guys that authored the NICHD Workshop. By all means. Don’t listen to me. Listen to them. They happen to be saying the same thing though, so…
Late decelerations are a normal physiologic response …
Just to be clear, “normal” does not mean universal. Not all babies have late decels. The babies who are doing just fine may have them, or not; but the babies who are not doing fine will have them. IOW decels are common, and sometimes are a “false positive” (i.e. the baby is fine). But if the baby is in trouble, it will have them.
All that we can do with current technology is identify all the babies who are having problems, plus a number of babies who aren’t (the false positives).
That’s a lot better than not being able to identify the ones who are having problems, but hopefully as technology develops we will be able to continually reduce the number of false positives.
Of course, when we do, I expect the natural birth crowd to reject the new technology because it is an “intervention.”
The majority of babies? How many babies does an obstetrician or a midwife deliver in their career? 3 000? 5 000?
How many babies am *I* going to deliver in my lifetime? Even without birth control (which is marvelously available to me”, I am not likely to give birth to more than 20 in my lifetime. The majority of them getting away unscathed isn’t good enough for me, sorry. Not when we have the means to greatly increase the chance that ALL of them make it out unharmed.
The majority of babies for the medical staff is vastly different for the majority of HER babies for a mother.
Is that the belt they put around my abdomin in labor?
Yes, then if you have a baby in distress (as I did) they sometimes break your water/amniotic sac, and do internal monitoring which means they attach an electrode to the baby’s head.
I had meconium stained waters and they wanted to see how the baby was tolerating labor before they decided what the best next steps were.
I have zero expertise in this area but I will say that for the two days during my induction that they were using the belt, most of the midwives attached it and then buggered off. At one point, my son kept kicking it off and I had to keep repositioning it, and yet I was told it gave a ‘perfect’ trace. Which I can’t believe was accurate as the belt had spent most of the hour not measuring anything. Once they broke my water and attached the electrode directly on his head, that method appeared to be more accurate. It was also at that point that I had a midwife in the room with us the whole time, paying attention to the monitor. I am not surprised EFM isn’t accurate if it’s normally used the way it was with me. How can you say the belt is measuring anything accurately if you spend 90% of the time it’s attached in another room not paying attention to where the easily movable monitor is attached to?
At my hospital, the output of the monitor was displayed at the nurses’ station. When I scrunched down for the catheter placement, that changed baby’s heartbeat, (apparently, that’s common) and about three nurses rushed in to roll me on my side to try to fix the problem. So maybe they didn’t have to be in the room.
Yes, this. I used to work on an OB unit, and the fetal monitor tracings showed up on various screens all around the unit. Nurses kept an eye on the tracings, and scooted in if anything looked off.
When I gave tours I made sure to tell people that even if there wasn’t someone in the room with them, they were being watched.
The baby kicked it off completely several times and nobody reacted at all or came to check on us. I didn’t get the impression it was showing up anywhere else- there wasn’t even anyone at the nurses station half the time so I guess even if it had then there wasn’t necessarily anyone there to see it. Admittedly I was not in my own room, I was in the induction suite with a bunch of other ppl. We didn’t even have a dedicated midwife for several hours as the one looking after us was called off to attend to a homebirth. I had the distinct impression we were pretty much the bottom of the pile when it came to what resources they had that day.
I had abdominal pain at 28 weeks pregnant with my first and we went to L&D to get checked out. After they assessed me and figured out I wasn’t actually in labor, they still kept the belts on me until they were ready to let me go and we had to cool our heels for a bit. At one point I got out of bed and a nurse came and very nicely asked me to get back in bed because the belts weren’t reading properly.
I was definitely monitored from outside my room. I had an overnight induction and was advised to try and sleep. I got to where I was only semi-conscious between contractions. The room was dim, only my mother and I were there. And then the lights came on and my midwife started having me change positions this way and that because someone spotted something on the monitor from outside the room.
It’s likely the nurses looked up at the flat parts and thought, “Belt is off — of look, mum got it back on again.” Non-recording is way different from an abnormal trace, enough that the nurse can tell the difference.
The external belt can also be a record of contractions, rather than heartbeat. I wore it for that reason, twice a day, hour at a time, for the last seven weeks of my pregnancy. I wore it continuously when I was sent to the hospital, each time. The last time I went in with steady contractions — mild but steady — they put the belt on me and let me get some sleep. It slipped off during the night, so there was no trace, but when it was put back on, the contractions were still there, still steady. The doctor came in and looked at the trace, and said, “Are you going to contract or not?” When we explained what had happened, the doctor accepted that I was in mild labor and recommended that we go ahead with the planned csection, becasue she felt I wasn’t going to stop and the girls were big enough to take.
I had lots of contractions. It caused me problems because I was contracting well but wasn’t dilating and they used the readings to conclude that I was doing well and didn’t need the induction started and nobody got around to doing a VE for hours. I got there at lunchtime and they eventually administered a pessary after 10pm. So I got to have even stronger contractions all the way through the night and not sleep at all. It was not a fun time.