Frequently Asked Questions
When we talk about fetal monitoring, I am sure that most of you see a woman in bed with straps around her pregnant form attached to a beeping machine. That is one type of fetal monitoring, electronic fetal monitoring. In this FAQ I hope to show you the different types of monitoring, the benefits and disadvantages of each type of monitoring, and how to use monitoring to help you achieve a safe, and happy birth.
Topics covered in this FAQ:
- What is fetal monitoring?
- Define the types of fetal monitoring
- What are the benefits and risks?
- Which is right for me?
- Problems with Standard Practices of Fetal Monitoring
- Research on Fetal Monitoring
- Personal Stories about Fetal Monitoring
Fetal monitoring is defined as watching the baby's heart rate for indicators of stress, usually during labor and birth.
- Fetoscope: This is a special type of stethoscope used for listening to a baby. There are many types of fetoscopes available, and a regular stethoscope works as well. This can usually be used after about 18 weeks.
- Doppler: This is a handheld ultrasound device that transmits the sounds of the baby's heart rate either through a speaker or into ear pieces that are attached. This can generally pick up heart tones after 12 weeks gestation.
- Electronic Fetal Monitoring: This is an ultrasound device used during labor and birth, or during certain testing (non-stress test, contraction stress test, etc.) to record the baby's heart rate, and sometimes mother's contractions. It can be used intermittently or continuously.
- Internal Fetal Monitoring: It is an internal monitoring with an electrode attached to the baby's head to record heart tones, and a pressure catheter to record contractions. This is also used during labor and birth, however, it is not used intermittently.
- Telemetry Monitoring: It is a lot like the regular Electronic Fetal Monitoring, however, one can maintain mobility.
- Fetoscope: This method is non-invasive, simple to use, and has a live person on the other end (This can prevent some of the errors that are mechanical.). This gives mother the mobility to deal with her labor, shower, etc.. It does require that the person using it be trained, although it is a standard procedure taught in every medical and nursing type institution. In the case of high risk, induced, or with certain medications, it cannot provide the round the clock monitoring that may be necessary.
- Doppler: This method is also used intermittently, requires little training to use, has a live person on the other end, and allows mother to maintain her mobility. It may also be easier to use during a contraction. This device does use ultrasound and does not provide the continuous monitoring needed for high risk labors.
- Electronic Fetal Monitoring: This method provides beat to beat view of the baby's heart tones, in relationship to mother's contractions. This may be used either continuously or intermittently. This is a benefit for the high risk mother, but of questionable benefit to the low risk mother. This method does use ultrasound; leaves room for mechanical error, which may cause incorrect interpretation, unnecessary interventions etc.; loss of maternal mobility (when in use), which may slow labor; and may switch attention from the mother to the machine.
- Internal Monitoring: This is more accurate than the electronic monitoring, does not use ultrasound, and can provide continuous monitoring for the high risk mother. This method requires that your water be broken (An amniotomy will be performed if you water is still intact.), and that you be 2-3 centimeters dilated. Amniotomy adds risks of its own. However, the risks and benefits of each procedure must be weighed. This type of monitoring is almost exclusively used in high-risk situations or when more accurate types of monitoring may prevent other unnecessary interventions. This type of monitoring also has been associated with fetal injury (from the electrode), infection for mother or baby, etc.
- Telemetry Monitoring: This is the "newest" type of monitoring available. It uses radio waves, connected to a transmitter on your thigh, to transmit the baby's heart tones to the nurses station. You maintain your mobility, and have constant monitoring, but again, continuous monitoring for the low risk mother is very questionable in benefit.
We have talked about the different type of monitoring available. There is no one right way for every woman. Depending on your choices of labor management, your monitoring will be tailored (If you talk to your care provider before hand, many have standards that you wish to avoid.) to your situation. If you are high risk, are induced, or choose epidural anesthesia you will be more likely to have continuous monitoring
Think about your labor choices and how you plan to cope with labor. Study the different types of monitoring and talk to your care provider. Be aware of what is going on with the standards of monitoring in your community.
The problems with standard fetal monitoring is that we tend to want to use continuos fetal monitoring on everyone. However, today we know that in most cases, routine continuous fetal monitoring of every woman does not improve fetal or maternal outcomes, it only tends to increase the cesarean rates. We have found that using a fetoscope or doppler is just as effective in predicting fetal well-being.
- The New England Journal of Medicine, March 7, 1996 Volume 334; #10 "Uncertain Value of Electronic Fetal Monitoring in Predicting Cerebral Palsy" Karin Nelson, MD; James Dambrosia, PhD, Tricia Ting, BS; and Judith Grether, PhD Editorial by Dermot MacDonald, MB, MAO (National Maternity Hospital - Dublin, Ireland) give an overview of the history of fetal monitoring and it's relationship to detecting intrapartum problems that could be possibly associated with cerebral palsy.
To quote, " ...the only clinically significant benefit from the routine use of EFM was in the reduction of neonatal seizures. The rates of intrapartum and neonatal death, short-term morbidity and long-term morbidity including cerebral palsy were similar whether the fetal heart rate had been monitored continuously or intermittently."
- MacDonald D., Grant A., Sheridan-Pereira M. et al. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. AM J Obstet Gynecol 1995; 152:524-39.
- Rosen MG and Dickinson JC. The paradox of electronic fetal monitoring: more data may not enable us to predict or prevent infant neurologic morbidity. Am J Obstet Gynecol 1993;168(3 Part I):745-751.
- More references also available
- Shy KK. Larson EB, and Luthy DA. Evaluating a new technology: the effectiveness of electronic fetal monitoring in. Ann Rev Public Health 1987;8:165-190.
- Thacker SB. The efficacy of intrapartum electronic fetal monitoring. Am J Obstet Gynecol 1987;156(1):24-30.
- Prentice A and Lind T. Fetal heart rate monitoring during labour-too frequent intervention, too little benefit? Lancet 1987;2:1375-1377.
- Grant A. Epidemiological principles for evaluation of monitoring programs-the Dublin experience. Clin Invest Med 1993;16(2):149-158.
- Vintzileos AM et al. A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation. N Engl J Med 1990;322(9):588-593.
- Sandmire HF. Whither electronic fetal monitoring? Obstet Gynecol 1990;76(6):1130-1134.
- Steer PJ et al. Interrelationships among abnormal cardiotocograms in labor, meconium staining of the amniotic fluid, arterial cord blood pH and Apgar scores. Obstet Gynecol 1989;74(5):715-721.
- Sykes GS et al. Fetal Distress and condition of the newborn infants. Br Med J 1983;287:943-945.
- Curzen P et al. Reliability of cardiotocography in predicting baby's condition at birth. Br Med J 1984;289:1345-1347..
This gives rise to concluding that the fetal monitor has now been evaluated by 12 prospective, randomized, controlled trials involving more than 55,000 infants with the complete understanding now that there is no improvement in outcomes due to this technology.
"We went round and round about the fetal monitoring. I asked the midwives to use a fetoscope, but the one I got most of the time wasn't comfortable with it and couldn't always find the heartbeat. We usually ended up with the doptone because she would get nervous and then I would too. (Once Jake was really active, I would tell her that he'd been moving a lot and that seemed satisfactory; I was also more secure with that.) We originally had in the birthplan that I wanted the fetoscope, no external monitoring and absolutely no internal (all assuming normal labor, of course). The midwife said that she was comfortable with that idea but that the L&D; nurses wouldn't be - they really liked to have the initial 20 minute strip to have as base information, and she felt it would make them nervous not to have it. (I think "them" also included her, but that's just an assumption.) After talking to Jim about it, we took it out of the birth plan and specified the initial strip and then monitoring with the fetoscope unless things weren't normal. We figured that we needed the nurses on our side, and if they were nervous about the information or lack thereof, we would all be uncomfortable. Actually, in the end I was really glad I'd made that decision because I pushed for six hours and Jacob's heart rate was strong all the way through. However, if that hadn't been the case the information would have been irrelevant." -Morgan
"I just wanted to add that ACOG (the national organization for OB/GYN's in the US) has the official policy statement that intermittent fetal monitoring is just as safe and effective as continuous. Their recommendations are a 20 baseline strip, then once every 1/2 hour (for 60-120 seconds!) in first stage, and every 15 minutes in second stage, as long as everything looks normal. I also agree with Naomi that maybe you should try and find a different hospital/doctor. If that is not possible, maybe you would want to hire a doula. They are there to be your advocate, and can be encouraging when other hospital staff members are trying to make you feel guilty or whatever." -Holly
"I had a very routine, almost "textbook" labor and delivery with no anaesthesia, and more importantly, a very experienced L&D; nurse who could tell how I was progressing without relying on monitors, pelvic exams, etc. I was on an external monitor for about 15 minutes toward the beginning to establish a baseline, and then for about 5 minutes every hour or so thereafter. I didn't mind it, and it was kind of interesting as a first-time mother to watch the screen on the monitor. It's just too bad you can pick your OB but not your L&D; nurse--I'd love to have that lady again!" -Kathy
"My wife looked like she was tied down, and no matter what I did, the machine kept drawing me to it. I just couldn't keep from watching the beeps. My wife would get angry every time I tried to say, 'Here comes a contraction...' I am not sure it was worth all of the trouble. Then after the birth the doctor said that we didn't have to have that kind of monitoring!" -Kevin
"We had a 15 minute strip done when we got to the hospital, then every hour a nurse would hold the transducer on for a minute to hear the heart rate. It was really nice because I didn't have to change positions, and I really only wanted to stand up. I liked not being bothered. I had agreed to more in my birth plan, but I couldn't bear the thought of laying in bed for 15 minutes out of every hour. We had a really good compromise." -Pam
"I was afraid of continuous electronic fetal monitoring, but my OB said that, while a good labor nurse is as good as if not better than the electronic monitor, such nurses are impossible to get. The hospital wanted 20 minutes of electronic monitoring upon arrival, and intermittent monitoring thereafter. Of course, I simply unplugged myself when I got up to go to the bathroom. Otherwise, simply from being tired after a long labor, I was immobile for more time than they would have asked for, for the monitor. Since I was immobile, there seemed no reason not to plug the thing back in. Otherwise, I expect that I would have unplugged it to walk around as I pleased. The monitor which is attached to the baby's head is potentially gruesome. We did have one, when it appeared that there had been meconium in the very small amount of amniotic fluid we had (that turned out to have been wrong). Everything was okay with this--no scar on his head, or anything-- but I'd still rather avoid it except when it's clearly needed." -Paula
"I had fetal monitoring on several occasions. The first was when I was in a car wreck at 27 weeks. The external monitor showed I was having contractions, but I didn't realize I was having them. (I did have a bad backache, but I thought that was either from the car wreck or lying in an uncomfortable position.) I had periodic monitoring at the doctor's office for preterm labor until I delivered (at 36 weeks). I didn't mind any of the monitoring; it eased my mind greatly on more than one occasion. In the beginning of my pregnancy, I was against routine monitoring, but I certainly was glad for it when things suddenly weren't routine anymore! I had an external monitor pretty much throughout my labor once I got to the hospital after my water broke. (only 6 hours, first baby!) It mostly didn't bother me, though a few times it got uncomfortable and I asked to take it off for awhile. Toward the end of the labor, Patrick's heart rate was dipping, and I was given oxygen. That helped, but he still had some trouble breathing once he was born (wet lungs). The monitor helped us deal with that ahead of his birth, and we had the NICU nurse in the delivery room, as well as the pediatrician who specializes in pulmonary problems alerted." -Melissa
" I chose to have an internal scalp electrode because I wanted to be ambulatory and "they" wanted to monitor me (baby) continuously and give me pitocin because I was ruptured for 12 hours without labor. My stomach was too "out front" for the external to stay on, and I was uncomfortable with doppler tones. It worked out very well. I remained ambulatory until 8 cm...literally until I needed to push." -Sheryl
"I was monitored for the first hour after I went to the hospital because my water was meconium stained when it broke (my son was born 10 days past my due date). After the initial monitoring, they let me out of bed to walk around, but I had to get back in bed every so often so they could hook the monitor back up to see how the baby was doing. He was fine and came through labor and delivery without a problem. In fact, they didn't even have the monitor hooked up to me during the delivery." -Terri
"External monitoring also doesn't have to be done in bed -- they hooked me up while I was rocking in a rocking chair (I was past being able to walk anyway). I even heard of electronic monitoring where the patient is able to walk around and an electronic sensor attached to the mother sends the baby's signal to the nurses station (or room, wherever the equipment is). I don't know how widely available this is, but it sounds like a great idea." -Colleen
"Well, you probably won't be given a whole lot of choice in the matter. Hospitals tend to have "policies". However, if your hospital policy is "flat-on-your-back-hooked-to-a-monitor-from-the-time-you-arrive-until-you-give-birth," I'd urge you to find a different hospital or insist on being allowed to move around. (Staying in bed isn't good for your labor.) When I had my baby, the hospital policy was 20 minutes on, 1 hour off the monitor, as long as things looked fine. I was also encouraged to move around in bed as much as I could while on the monitor. Once I was on medication (and therefore in bed anyway) I was switched to an internal monitor, which I found much more comfortable. (But my hospital doesn't routinely use them.)" -Naomi
"My story was slightly different......I was monitored off and on during about eight hours of labour. During the last (pushing) stage, Alexander's heart beat was dropping _seriously_ during contractions, but would pop up again to normal in between. At that point, they put on an internal monitor; I wasn't given a choice, but I wouldn't have objected anyway, because knowing exactly how Alex was doing was my primary concern. And in any case it didn't restrict my movement.....I was lying on my side (which was the position I delivered in) and I was, relatively speaking, quite comfortable. And I think it gave my OB enough information about Alex's condition so that she decided not to go with a C-section, but just encouraged me to work really hard to get the baby out as quickly as possible. I think it also alerted the junior resident, who actually did the delivery, to look for something unusual....which turned out to be the umbilical cord wrapped around Alex's neck a couple of times. My husband, who was slightly more lucid at the time, said that by the time the resident had said "The cord is wrapped around the neck two times" she'd had it clamped and cut. So I am an enthusiastic supporter of intermittent and internal monitoring if there is any question about the state of the baby; I think in my case it helped to avoid a C-section and possibly some serious injury at/during birth." -Sandra
"I entered the hospital after my water broke. I was having no contractions and there was meconium in the fluid. I did not CHOOSE fetal monitoring, I was told I had to have continuous monitoring. It was uncomfortable and restrictive -- I would have liked to have walked around and moved around some. I believe if I had had more freedom of movement I might not have needed the pitocin. The baby was clearly not in distress and I would have gladly submitted to intermittent monitoring. At some point, they switched to an internal monitor. I don't remember why, but it was toward the end and I was pretty out if it anyway. Deana had a small scab on her head from it, but otherwise had no ill effects. Same story for the second baby, meconium in the fluid when he stripped my membranes, so continuous monitoring, then pitocin, then epidural, etc. I'm obviously not an enthusiastic supporter." -Nancy
"I had External Fetal Monitoring when I was in Labor. It was an elastic cloth band that went around my abdomen (mountain). The put jelly on two round discs and put them under the elastic on my abdomen to hear the heartbeat. They could hear it fine that way. My knowledge at the time was very limited, I only knew what I learned at Lamaze class and a few books I had read. So I did not make any choice, I just let them do what they had to do. The only drawback is that I could not lay on my side with it because when I did I couldn't hear the heartbeat." -Sarah
"I was faced with the question of continual foetal monitoring, but I compromised by having the midwife stick the electrode on me and hold it on with her hand. She had to follow me around the room with the machine on wheels, but it worked very well. By discussing my worries with her, and getting her to see my point of view, I found she was happy to forget standard procedure." -Anna