Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Why do doctors cling to continuous fetal heart monitoring?

Alexander Friedman, MD
Physician
September 25, 2011
Share
Tweet
Share

My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.

So we gave medication to start labor, and the nurses placed a fetal heart monitor.

Worn like a belt, but higher on the abdomen, the ultrasound monitor would play a crucial role in the hours to come. It prints a read-out strip of the baby’s heart rate, and the pattern would guide us in determining whether the delivery would be natural or through cesarean section.

As I suspected, the baby’s heart-rate strip showed worrisome changes soon after labor began, and I knew it would get worse as labor progressed. We would fight through the night to have a natural delivery. But ultimately that single heart-rate test, which is surprisingly unreliable, would be a key factor in whether my patient would get a C-section or not.

Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates. A recent report detailed the dizzying increases: Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available. That rate has grown by more than 50 percent in a decade.

I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips.

A jagged pattern indicating increases in the heart rate reassures us that the baby’s brain is awake and alert, and that labor could continue. But a flat line or decreases in the heart rate after contractions make us think the baby is not getting enough oxygen and pushes us to do a C-section – delivering the baby through incisions in the abdominal wall and the uterus.

For the worst readings, we believed every second counted and rushed the surgery: If the baby wasn’t delivered one minute from the first incision into the skin, we had moved too slowly.

The complication we feared most was hypoxia, the baby not getting enough oxygen during labor. Going too long without adequate oxygen could result in a serious permanent injury, such as cerebral palsy, or even death.

No test is perfect. But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry.

Were we saving lives and averting disaster? Or were we performing unnecessary surgery?

Fetal heart-rate monitoring is a screening test. Good tests get several things right; they are cheap, detect a possible problem when there is still time to act, and minimize unnecessary follow-up tests.

Fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and expensive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.

ADVERTISEMENT

Why do doctors cling to continuous fetal heart monitoring? An obstetrician will likely point to the fear of being sued, but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don’t work and can cause harm. “It’s our bias that anything that can be quantified is an improvement,” said H. Gilbert Welch, a professor at Dartmouth Medical School whose research focuses on harm caused by screening and over-diagnosis.

“I think we get in trouble when we start promising things to . . . well [patients],” Welch said in an interview. “It is not that hard to make them worse.”

Throughout the night, I struggled with my patient’s bad fetal heart strip. I wanted her to avoid a cesarean section. To improve the strip, the nurses and I tried giving her oxygen, changing her position in the bed, even rubbing the baby’s head through the cervix to wake it up.

Finally, at 3 a.m., I felt compelled to recommend cesarean. The strip continued to look bad, and my patient’s labor progressed slowly.

We went to the operating room, and delivered the baby by cesarean. My patient’s child greeted the world pink and well-oxygenated.

The test was wrong again.

Alexander Friedman is a fellow in maternal-fetal medicine at the University of Pennsylvania.

Costs of Care has launched its annual 2011 healthcare essay contest, with the goal of expanding the national discourse on the role of doctors, nurses, and other care providers in controlling healthcare costs.  The contest will solicit stories from care providers and patients across the nation that illustrate everyday opportunities to curb unnecessary and even harmful health care spending on a grassroots level. 

Costs of Care will award $4000 in prizes to top submissions. Two $1000 prizes will be reserved for patients, and two $1000 prizes will be reserved for care providers.

Submit a guest post and be heard on social media’s leading physician voice.

Prev

My good intentions had helped start a reaction

September 25, 2011 Kevin 0
…
Next

Social media and the modern day House of God

September 26, 2011 Kevin 4
…

Tagged as: Specialist

Post navigation

< Previous Post
My good intentions had helped start a reaction
Next Post >
Social media and the modern day House of God

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More in Physician

  • Physician patriots: the forgotten founders who lit the torch of liberty

    Muhamad Aly Rifai, MD
  • The child within: a grown woman’s quiet grief

    Dr. Damane Zehra
  • Why the physician shortage may be our last line of defense

    Yuri Aronov, MD
  • 5 years later: Doctors reveal the untold truths of COVID-19

    Arthur Lazarus, MD, MBA
  • The hidden cost of health care: burnout, disillusionment, and systemic betrayal

    Nivedita U. Jerath, MD
  • Why this doctor hid her story for a decade

    Diane W. Shannon, MD, MPH
  • Most Popular

  • Past Week

    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
    • Physician patriots: the forgotten founders who lit the torch of liberty

      Muhamad Aly Rifai, MD | Physician
    • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

      Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO | Meds
    • Why physicians deserve more than an oxygen mask

      Jessie Mahoney, MD | Physician
  • Past 6 Months

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • A faster path to becoming a doctor is possible—here’s how

      Ankit Jain | Education
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions
    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
  • Recent Posts

    • Physician patriots: the forgotten founders who lit the torch of liberty

      Muhamad Aly Rifai, MD | Physician
    • The child within: a grown woman’s quiet grief

      Dr. Damane Zehra | Physician
    • Avarie’s story: Confronting the deadly gaps in food allergy education and emergency response [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why the physician shortage may be our last line of defense

      Yuri Aronov, MD | Physician
    • 5 years later: Doctors reveal the untold truths of COVID-19

      Arthur Lazarus, MD, MBA | Physician
    • The hidden cost of health care: burnout, disillusionment, and systemic betrayal

      Nivedita U. Jerath, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 10 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
    • Physician patriots: the forgotten founders who lit the torch of liberty

      Muhamad Aly Rifai, MD | Physician
    • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

      Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO | Meds
    • Why physicians deserve more than an oxygen mask

      Jessie Mahoney, MD | Physician
  • Past 6 Months

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • A faster path to becoming a doctor is possible—here’s how

      Ankit Jain | Education
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions
    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
  • Recent Posts

    • Physician patriots: the forgotten founders who lit the torch of liberty

      Muhamad Aly Rifai, MD | Physician
    • The child within: a grown woman’s quiet grief

      Dr. Damane Zehra | Physician
    • Avarie’s story: Confronting the deadly gaps in food allergy education and emergency response [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why the physician shortage may be our last line of defense

      Yuri Aronov, MD | Physician
    • 5 years later: Doctors reveal the untold truths of COVID-19

      Arthur Lazarus, MD, MBA | Physician
    • The hidden cost of health care: burnout, disillusionment, and systemic betrayal

      Nivedita U. Jerath, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Why do doctors cling to continuous fetal heart monitoring?
10 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...