Birth Preferences (Part 5): Fetal Monitoring

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A lot of families I support as a doula aren't aware that they'll likely have a choice when it comes to how their baby is monitored during labor, and don't realize how large an impact this choice can have on how a birth unfolds.  So, what are the different types of monitoring, and which is best for you?  Read on for a little background info that may help when discussing this important decision with your provider.

History of Electronic Fetal Monitoring

Electronic Fetal Monitoring as we now know it (think straps around the belly and continuous heart rate tracings feeding onto a strip of paper) is a relatively new-ish thing.  Long story short, listening to fetal heart sounds as a way to determine fetal wellbeing started gaining in popularity in the 1800's- at which time the method was simply listening with one's ear next to a mother's abdomen.  It wasn't until the early 1900's that the fetoscope was invented and intermittent auscultation (IA), a systematic method of listening to the fetal heart rate during labor, became widely recommended.  IA remained the standard of care until well into the 1970's, when Electronic Fetal Monitoring, commercially introduced in the 60's, gained in popularity.  It was also during the early 70's that the fetal scalp electrode used in internal fetal monitoring was introduced. (source)

Types of Monitoring

So, basically we have two different types of monitoring used today:

1) Electronic Fetal Monitoring  

  • Elasticized belts hold sensors using doppler ultrasound onto the mother's belly for external monitoring of the fetal heart rate (usually continuously) 


  • A fetal scalp electrode, placed under the first layer of the skin on baby's head is used for internal monitoring of the fetal heart rate (always continuous, more precise, and often used in high risk situations) 

2) Intermittent Auscultation

  • A fetoscope is used intermittently to listen to the fetal heart rate externally, usually every 5-30 minutes depending on risk status and stage of labor
  • A handheld doppler ultrasound transducer is used intermittently to listen to the fetal heart rate externally, also every 5-30 minutes depending on risk status and stage of labor

What the Research Says

The interesting thing, as stated here, on an online EFM training module created by Howard Herrell, MD, FACOG, :

"Until recently, as new technologies have emerged, they have been adopted into clinical practice before large studies were carried out regarding their efficacies. IA was widely used for four decades before the first randomized clinical trials (RCTs) and EFM was used over a decade before the first RCT was available... Cochrane has published a meta-analysis comparing EFM to IA which showed no difference between the two in low Apgar scores, NICU admissions, perinatal deaths, or the development of Cerebral Palsy (CP). There was a 50% reduction in neonatal seizures, but a significant increase in operative vaginal delivery and cesarean delivery rates. Vintzeileos et al did show a reduction in perinatal death in the EFM group as compared to IA, on the order of one perinatal death prevention for every 1000 births, but with an associated increase in the cesarean delivery rate of 2-3 fold. Notwithstanding these controversies, EFM continues to be widely used today as a routine monitor of fetal wellbeing."

So why is continuous EFM still the standard of care, "despite evidence suggesting it is ineffectual, prone to interpretive errors, has a 99% false-positive prediction of fetal distress, has increased the incidence of cesarean delivery, has not reduced the rate of cerebral palsy (CP), and has not produced better perinatal outcomes", as this article states?

Well, per Evidence Based Birth, "until ACOG makes a clear statement that intermittent auscultation is preferable to EFM, obstetricians in the U.S. will probably stick with the status quo of EFM—even though the research evidence overwhelmingly supports intermittent auscultation, and this evidence has been around for more than 30 years now. The American College of Nurse Midwives openly disagrees with ACOG and says that intermittent auscultation– not electronic monitoring– should be the preferred method."

As it currently stands with ACOG, "Given that the available data do not show a clear benefit for the use of electronic fetal monitoring over intermittent auscultation, either option is acceptable in a patient without complications." (ACOG, 2009)."

Other Considerations

While many hospitals, including the SSM St. Mary's and UnityPoint Meriter in Madison, have portable EFM units allowing a laboring woman to remain mobile and even get into the tub, the fact remains that continuous monitoring can create fear and distraction during a time when remaining calm and focused is really important in allowing birth to progress normally.  It can be very difficult to get good tracing as the mother moves about, requiring frequent interruption for adjustments to straps or wireless patches.  It may also open the door for premature or unnecessary intervention.  On the flip side, of course there are times when continuous monitoring may be medically necessary, and some parents just feel more comfortable with continuous monitoring- there is nothing wrong with making that choice.

Bottom Line

As with all of the options you are faced with while exploring your birth preferences, you are in the driver's seat, and ultimately you should be given a choice in how your baby is monitored after being presented with the benefits and risks as they relate to your unique situation.  It's super important that you have discussions about all your birth preferences with your provider before you go into labor to ensure you are on the same page, and the way your baby is to be monitored is no exception.

Disclaimer:  The content found on this blog is meant only to provide general information and is not a substitute for professional medical advice.

See previous posts in this series:  Birth Preferences (Part 1): The Importance of Informed Consent and the "Overdue" BabyBirth Preferences (Part 2): Vaginal ExamsBirth Preferences (Part 3): Birthing Environment and Choosing a Care ProviderBirth Preferences (Part 4): Labor Coping Strategies

Written by Angie Traska of Align Doula Services, providing intuitive, attentive doula support that aligns with you.  Serving Madison, WI and the surrounding areas.  Looking for doula support or lactation counseling in Madison?  Contact me here.