Wednesday, 28 April 2010

The Cardiotocograph test: Absurd at best?

When I did my midwifery training in the 70's, the Cardiff Infusion pump was used to induce labour. The women were placed flat on their backs and monitored with a cardiotocograph machine. The cardiotocograph machine recorded an approximation of the fetal heart rate with an ultrasound transducer. There was also a capacity to record the uterine activity, but the uterine activity was actually monitored by the Cardiff pump machine. Women had their amniotic sac membrane broken with an instrument called a amnihook. A thin plastic tube with a pressure monitoring device was inserted into the woman's uterus through the cervix and into the sac next to the baby. The pressure monitoring device was hooked up to a machine called a Cardiff pump. The pump also provided a syntocinon (a synthetic hormone designed to induce labour) infusion into the woman's blood stream via a cannula in a vein in her arm. The rate of the infusion was set according to the pressure of the uterine contractions. The theory was that the rate of infusion of syntocinon would be governed to deliver the right amount of uterine stimulating drug and no more.

Of course there were problems with that process!

The Cardiff infusion pump has been phased out because of all the problems, but the cardiotocograph lives on, despite evidence that it is not reliable, overly useful, accurate nor does it enable women freedom of movement, known to provide the best opportunity to birth well and have optimal oxygenation of the woman and her baby.

The cardiotocograph machine has become the constant in the standard birth room and has taken the place of the midwife in the role of being 'with woman'.

An insightful honest account of the uselessness of cardiotocograph monitoring of labouring women is provided in the link below.

Test leads to needless C-sections | Philadelphia Inquirer | 04/26/2010

What's known is that the rampant use of cardiotocographs has increased the caesarean section rate with no benefit.

Dr Alex Friedman, a Fellow of Maternal-Fetal Medicine at the Hospital of the University of Pennsylvania said: 
"A 2006 analysis by the British Cochrane Collaboration, evaluating all available research, found that fetal heart monitoring failed to reduce perinatal mortality - the risk of a baby's dying late in pregnancy, during birth, or shortly after birth - and increased cesarean section rates and forceps deliveries, compared with listening to a baby's heart rate intermittently".

Steven Clark and Gary Hankins, two prominent obstetricians said
"A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best," they wrote in the American Journal of Obstetrics and Gynecology. "Electronic fetal heart rate monitoring has probably done more harm than good."

and The Doctors' Channel has an excellent video explaining that C-Sections, necessary or not increase maternal morbidity and mortality.

So why are they still done so mindlessly?

The answer is best summed up by this comment:

"Why do doctors cling to continuous fetal heart monitoring? An obstetrician will most 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".


Anonymous said...

One time when I was assisting a woman giving birth in a well respected Sydney delivery suite, I asked the midwife on duty if the monitor could be taken off my friend as she was extremely uncomfortable and feeling irritated by it. The answer from the midwife? "if we take it off I'll have to come in here every 15 minutes to find the baby's heartbeat with the doppler, we're simply too busy for that."
oh, ok then... (??!!!!)

Carolyn Hastie said...

Thanks for your comment Nic. A sad example of what passes for midwifery care now surpassed be the midwife machine! 1984 came and went (if anyone knows that book about a ghastly machine driven future) but we still live with the consequences of the mechanistic revolution. Some places have even have centralised monitoring. That means the machine watchers can sit at the desk and observe all. No wonder the new buzz term is 'fetal surveillance'.