#75 | Fetal Monitoring and Fetal Distress with Midwife-Author Amy Romano

To monitor or not monitor: that is the question.  More specifically, how to best monitor your baby in labor without causing undue worry and intervention is the question of today's episode.  Author, midwife, and researcher Amy Romano MBA, MSN, CNM tells us that a large body of evidence on fetal heart rate monitoring indicates that we are likely looking for and finding problems that don't actually exist when it comes your baby's heartbeat in labor.  And there is a significant cost to both mom and baby including higher rates of cesarean section, more forcep and vacuum deliveries and fewer vaginal births.  In today's episode you will learn:

1. The difference between Intermittent Auscultation (IA) and Continuous Electronic Fetal Monitoring.

2. The evidence or lack thereof to support Continuous Electronic Fetal Monitoring (CEFM) and the risks of EFM.

3. How to ask your hospital and care provider for Intermittent Auscultation for fetal monitoring in labor.

Amy Romano MBA, MSN, CNM

#5 | Preterm Babies & the Case for Midwifery Care: Interview with Midwife/Author Amy Romano

Optimal Care in Childbirth: The Case for a Physiologic Approach

Institute for Perinatal Quality Improvement

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Transcript

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast.
 Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Amy Romano is back in the studio with us today. Amy's a certified nurse midwife with a master's in nursing and an MBA from Yale University. She's an experienced midwife and a healthcare leader who's influenced maternity care policy and practice nationally. She also co authored the award winning book, optimal care in childbirth, the case for physiologic approach. Amy, thanks for being back with us today. I'm so glad to be back. We want to talk with you today about electronic fetal monitoring. And is it fair to say no matter who the provider is, everyone needs to get the heart rate throughout the birth that's not in dispute. Is that in dispute? I think it's, we can talk a little bit about that. You know why it's necessary, but I would say yes, as a premise. It's important to listen to the heart rate in labor, and is there a certain protocol for doing that? There's a few different protocols. So there's really two approaches to Listening to the fetal heart rate. One is continuously using the electronic fetal monitoring machine that you probably have seen if you've been in a hospital that involves straps around the belly and continuous listening that actually traces out a pattern that you can visually look at an assess. So that's one model. And the other model is called intermittent auscultation, which is intermittent meaning periodically throughout labor, it generally gets more frequent as labor progresses, but it's just an occultation means listening. So it's instead of tracing and looking at a visual to interpret the heart rate, you're listening, you're counting and you're assessing whether the heart rate is normal, or it's increasing, decreasing, and so on, and looking for patterns. And then there's a couple of like hybrid approaches that sometimes are used where either both of those methods might be used at different times and labor, or sometimes you will use the machine more intermittent. Well, you put people on the machine for maybe 10 minutes out of every hour or 10 minutes out of every 30 minutes or something like that and take breaks from it. But to get back to your initial question, I think it's good to sort of read the conversation and what's happening while you're, you know, what's the fetal heart rate? Why is that our assessment of fetal well being as opposed to something else. So, you know, anytime someone's in labor, it's important to be paying attention to the moms well being the fetal well being and the overall progress of labor. And with Mom, you can ask her how she's doing, you can assess various vital signs with the fetus. There's not much you can go on. It's really the heart rate, maybe fetal activity movement, but that is harder for women to feel in labor, and it's hard to assess. And so we listen to the fetal heart rate because it does fluctuate in ways that can be associated with how the baby's doing, there's a belief and we'll get into sort of how real it is. That the patterns are that the baby's heart. Makes are associated with how much oxygen the baby's getting through the placenta. And so the baby's overall physiology is that they're still throughout labor. And for a couple minutes after they're even born, they're getting their oxygen through the placenta. So maternal oxygenated blood is exchanging oxygen in the placenta, the baby gets it. The other important piece of that is the ability to sort of get rid of the other gases like the carbon dioxide and other things that the baby is using and metabolizing. So a decrease in the heart rate is thought to be associated with less oxygen and potentially a buildup of those other factors that the baby needs to metabolize and get rid of. So that's the first premise. And then the next premise is that decrease oxygenation and labor is associated with poor condition at birth. So you could say like, Oh, well, the baby's heart rate is decreasing. That means it has less oxygen, and so we're expecting this baby to be born in a different Stay maybe low Apgar scores, that kind of thing. And then the next part of the premise is that a baby That's born in a depressed state that might need some stimulation at birth is at risk of having some poor long term outcome. And so, fetal monitoring, whether it's like listening, whichever method came on the scene, really out of that trio of beliefs that like we can listen to the baby's heart rate, it'll give us useful information about the oxygen status, which gives us useful information about how this baby's gonna be at birth, which can help us prevent some of these catastrophic long term outcomes like death, cerebral palsy, you know, mental conditions that can relate to lack of oxygen at birth, but argument kind of breaks down at each of those terms.

Are those premises in question? Are you implying that they're in question?

I am. I would say that they're not broadly in question. People don't question them as often as they should. But there is a large body of evidence that suggests that these fluctuations that we see in life are not strongly associated with condition at birth. And the condition of birth is not strongly associated with the long term condition of the baby. So there are some associations there. But the large majority of babies that have changes in the heart rate and labor are going to be born fine. And the large majority of babies that are born with a low Apgar score or needing some better recessive station are going to be fine. So there's always this possibility that the test result is wrong. And mathematically speaking, the more frequently you test somebody, the more frequently you're potentially getting a false positive. And then when you turn that into like, while we're just going to continuously run this test through a period of hours and hours, you're very, very likely at that point to have a false positive and to have something that looks like it could be a problem, but turns out not to be.

So can we talk first about the various methods a provider can use to get the heart rate?

Yeah, can we just start really high level So the tools are the continuous electronic fetal monitoring machine, which has two belts for external monitoring. One of the belts is measuring the contraction strength, and one is measuring the fetal heart rate. There is a variation of this that involves internal monitoring where either or both of those things can be measured with tools that are inserted internally. So the internal fetal monitor is plugged into the same machine and produces the same sort of visual pattern. But it's that's the one that is actually attached to the baby's head through a little screw.

Yeah, I'd love to ask you about that later. Yeah, I am not sold on that at all. And I want to hear the best argument for it. There's one out there, I need to hear it.

Yeah. So we'll get back to that. Then there's another internal monitor that measures the, the pressure of the contraction more reliably than the external monitor so you can have one or both of those. You can also use that same machine, typically Just the external version for what's called intermittent monitoring. That just means putting the machine on for, you know, some period of time, maybe 10 or 20 minutes per hour, let's say. So that's, that's all with the machine. And then the other method, which is intermittent auscultation, just periodic listening. That is typically done with a Doppler, which is the fetal Doppler. It's should be familiar from your prenatal visits. It's, you know, the handheld device. And it's the same thing. There's in the earlier studies and also in some other parts of the world. a fetus scope is frequently used for intermittent auscultation. And that's a device. There's a few different variations of it, but that's basically like a stethoscope. That is pressed against the belly and the person listens and that when you're listening, you know you're not using any ultrasound waves. So some people prefer that but it really is challenging to perform that type of listening in labor when there's you know, the woman Trying to move about and she might be making noise and you know, there might be noise in the environment you might want. You know somebody else if I'm the midwife at a birth, and I want my nurse to be able to also hear what's going on that can only be achieved with a Doppler. So in this day and age, and in the United States, intermittent auscultation is typically done with the Doppler device, it can, it can be nice sometimes to use that in early labor, I think. But as we get into second stage and pushing the use of fetus scope can become really, really challenging. And it's hard you can't do it. For instance, in water, somebody wants to be in a tub.

There's the so there's the Doppler, which is a method of intermittent auscultation for a hearing intermittently at some periodic interval. And then there's continuous electronic fetal monitoring. Once people have that strapped on, they tend to leave it on. I've had clients to have it taken on and off and on and off during labor, but it becomes a burden. Yeah, I tend to leave it on just for convenience after a while hospitals have really embraced electric Chronic feel monitoring. It's part of the culture. It's like structurally ingrained. So electronic fetal monitoring came on the scene in the 60s and 70s. At that point, there already had been this wave of increased auscultation, meaning listening and labor because there was it was like, you think back to the 60s, it was a very sort of scientific era. And we were coming out of the era that your listeners may or may not be very familiar with, but where we were basically knocking women out completely for birth, giving them very strong drugs that created a lot of neonatal depression. A lot of babies born in poor condition, because of the drugs on board with the mom. And plus, they're being like, extracted with forceps and stuff. So there's like all kinds of reasons why babies might be born in poor condition. And then there's this new tool of like, Oh, we can listen, we can listen to the heart rate, we can understand what's going on and we can prevent so all of this was introduced in hopes of preventing these poor outcomes, which obviously should be all of our goals. But it was as though Chronic fetal monitoring was suddenly going to save all these babies. Exactly, otherwise, exactly. So really was one an example of something that was invented and swept very, very quickly across the country and other parts of the world, although not everywhere. So we went from this folksy way of listening here and there throughout labor and to having these machines that are going continuously and it really, in addition to changing the experience of giving birth, it also just changed the whole culture and structures in the healthcare system. So hospitals spend a lot of money on these machines they To this day, they spend a lot of effort training everybody in the machines, you do these annual trainings to make sure everybody knows how to interpret everything and and there's been areas where they've added different things to fetal monitoring. We're now we've got internal fetal monitoring and for a while when Trisha when you and I were in school, they were doing like fetal Pulse oxygenation, which is just another in Scout, and scout pH there's like all these things, which is scout pH is literally like cutting the baby's head getting a blood sample while they're still inside. Let me guess it didn't take it didn't take.

It didn't prove to deny any benefit new babies were coming out with cuts on their head.

Yeah. So, so and hence ego or my, my co author in the book talked about, it's like rearranging deck chairs on the Titanic, they just, you know, by by the 70s, it was clear that the premise of all of this was shaky to begin with that probably we're not having the benefit that we think we are. So they just kept sort of tweaking the technology rather than taking a step back and saying, maybe this approach doesn't work.

I just like to clarify something for our listeners, though, you were talking about how there's this risk of creating all of these false positives, particularly when you're doing continuous electronic fetal monitoring, which we're going to get into The problem with false positives is then we're taking action. And we're performing interventions that carry risks themselves. Correct. So the problem with these false positives is we now can be unnecessarily intervening, thereby creating the negative outcomes. We, we were portending or attempting to try to avoid in the first place, yes, or, you know, at a minimum, not effectively preventing those problems. But yes, definitely potentially introducing new problems based on not just the interpretation and response but also the technology itself. It involves it really puts the machine at the center of the process. It puts the woman in the bed, it keeps her strapped to their, it makes her so part of the machinery of labor. And you contrast that to an area where none of this technology ever showed up, which is birth centers and home birth, where you see women moving Moving around, following their instincts, using movement and getting lots of hands on support, it's hard if you've ever taken care of someone in labor, it's hard to like get in there and press on their back or help them into positions when they're on the fetal monitor. Because you just have to sort of accommodate the machine and all of the wires and things. And if you if she moves this way, or that way, you can't hear anymore and then you're like, Oh, we can't hear you. Can you? Can you move like this or stay like that?

I can remember as a student midwife, how so much of our time was spent adjusting that monitor, as opposed to actually engaging with the woman and feeling her and helping her and it was always about the monitor like, Oh, you really do another second? I can't hear. I mean, it was almost as if a monitors having the baby and not the woman.

Yeah, yeah. Another thing that changed when fetal monitoring came on the scene is that nurses and you know, midwives used to be taken care of women, one on one really in the room. And then this monitor showed up. And then a few years later, the ability to beam the monitor findings to a screen that's in the nurse's station came up. And then by the way, now that's at home there, the doctors are tracking these things from their houses now not even from the nurses, the Urbino from the provider station. So, yeah. So which completely breaks down the premise that like this technology, is there that so that we can intervene in a more timely manner? Exactly. How is that helpful? I guess the doctor doesn't relay the information to somebody else at the hospital who may act more quickly.

Yeah. And some of that is because it can take some time to really interpret and understand and for everybody who's looking at the same strip to agree, what are we seeing here is this you know, just sort of a pattern that we should be concerned with. So there's depending on what the results are of the test, there's a category one, category two, or category three. So this is new terminology that came on the scene. And it's like everybody can agree that Academy Every one tracing is good and the baby's fine and well oxygenated. And everybody can agree that a category three is like, we got to deliver this baby now. But there's a lot of category two that happens. And that's the gray area where there can be delays and sort of figuring out what to do.

Amy, what is the case for doing intermittent auscultation as opposed to continuous electronic fetal monitoring?

So there are a bunch of studies, I think there's something like 13 studies 37,000 people, they looked at comparing these two methods, across time. caveat being that these studies were done in the 70s and 80s, largely, some of them into the 90s and 2000. So things were kind of different overall. But the vast majority of outcomes, there's absolutely no difference and in particular, the outcomes that were the whole basis for introducing continuous electronic fetal monitoring like reducing perinatal death, reducing cerebral palsy reducing app or you know low Apgar scores or admissions to the neonate No ICU, there's no statistical difference across, you know, many studies on any of those outcomes. And there is an increased likelihood of Syrian birth with continuous fetal monitoring, particularly for the indication of fetal distress. And so that's where you're seeing these kind of false positives potentially. And then there's an overall increase in the use of vacuum and forceps delivery, as well as a decrease in spontaneous vaginal birth. And then there's one outcome that does seem to favor continuous fetal monitoring, and that's neonatal seizures, which don't happen very frequently. And they're traveling obviously, when they happen, but they're not associated and in most cases with long term poor outcomes, and also in the studies, you would have to continuously monitor 670 women to prevent one case of neonatal seizure, and that's sometimes how you look at literature. It's like what I never seen and in that literature myself is what happens to be 670 women when you intervene. I never see that with pitocin or anything else. It's like, Well, okay, it's worth listening to if, if you do this and it saves that one baby, but what are the outcomes over here? Right?

So you're trading off in 70. Right? All the all of the  C-section access and instrumental vaginal births. There's always this assumption, right, that they turned out fine, right?

Now. I do want to ask you before you continue. You mentioned those studies are a little bit old. Have there been any recent studies that negate any of those findings? Are they simply not looking? No, they're not looking anymore because there's not it's so ingrained as the standard of care. It's now considered unethical to randomize women to you know, not have the standard of care even though the standard of care isn't evidence based. All of the professional organizations including American College of ob gyn, American college nurse midwives, and the Association of women's health, obstetric and neonatal nurses, all have professional guidelines saying that intermittent auscultation is appropriate for women at low risk of obstetric complications. There's not a lot of consensus about what that means low risk. Interestingly, most people don't know this. The studies included all kinds of people at high risk. It was like people on pitocin people with preterm labor, people with twins, all kinds of people. And even in the studies that included high risk women, there's still no difference between auscultation and continuous monitoring. So there's no real consensus about who's low risk who's you know, eligible versus ineligible, but everybody generally supports it as an evidence based option. But why it's not happening is really kind of cultural factors. And women. It's just, you know, it's part of the landscape as we talked about, but I think one of the factors that I've spent some time on recently is there's a real lack of skill in the performing And interpreting auscultation because it's been so swept out of the way. So you're starting to see some hospitals be like, okay, yeah, we'll support intermittent auscultation. We'll put out a policy saying, you know, these are the eligibility criteria to have intermittent auscultation. But it comes up against nurses who like don't know what how to do it, because nobody has properly trained them. The Doppler we're talking the Doppler Yeah, because it's it, there's, there's a technique to it, and it's not super complex, but you do need to learn it. And there's a little bit of terminology around it, there's some standards of how you should be documenting it. And unless a hospital is going to invest in making sure that everybody knows this, and that we're all using the same language. These are the kinds of things they invest quite a lot of money on. For the continuous fetal monitoring style of this. It's like everybody needs to pass the course every year. Everybody needs to be documenting, using the same language and communicating correctly about it. We're going to configure our electronic health record to be able to do that make sure it can get the data out of the thing. So there's like all kinds of sort of structural things that hospitals do to support continuous fetal monitoring, but they haven't invested in those similar types of things to support intermittent auscultation. So it's just like it's a major system overhaul.

It means the system overhaul. Yeah, and a real commitment, I think to choice.

I've heard the argument too, about cost that to provide intermittent listening, you need one on one nursing care, which is not always available. And that would be a really big cost to institutions. But continuous monitoring costs a lot of money as well. It does, is it really, and that different to to provide that one on one. When you're doing intermittent listening, you do have to be a lot more available. I mean, at times you have to be listening every five minutes.

So I want to dispense with some of the talking points about staffing levels because it is important to have adequate staffing to safely take care of people. And if you can't get a nurse in the room at least every 30 minutes in active stage and, and you know more frequently in second stage, then that's not providing safe care, regardless of whether it's intermittent auscultation, or continuous fetal monitoring. It's also already the national standard of care to have one to one nursing care in the second stage of labor. So it is true that you're escalating more frequently in the second stage, and it's it's kind of an intensive thing. You're listening every five minutes in most cases. And of course, there's like documentation every time you listen. So those are real issues, but you still need like, the idea that you need more nursing care when you have internet and auscultation sort of embeds in it the notion that the only thing that nurse is there for is to listen to the baby and tell the doctor when you know, there's something concerning happening. And of course, there's all kinds of things that nurses can and should be doing for women other than fetal assessment. And so and that's one of the things that we've traded off as, like, as we invited in continuous fetal monitoring. It's like the nurse, the role of the nurse really transformed and, you know, really the role of everybody transform the role of the woman certainly was transformed. And so, you know, there are times when a hospital legitimately needs to put somebody on a monitor, to sort of sort out staffing challenges, you know, you cannot predict when four people are going to show up on the unit at the same time with different you know, needs and active labor and so on. So, that's part of it, but I do think it also can become a convenient excuse for why not to implement intermittent auscultation and you know, what they should do is have a policy that states sort of like the minimum staffing level in general and and absolutely do it they talk about their teacher to student ratio, with pride and, and hospitals should do it. And it to me it it bolsters the case for using a Doppler or intermittent auscultation. Like this, we do this because it also, what also comes with it is that you'll have more one on one support.

Yeah, that's the hospital I want to go to.

Yeah, I mean, it's so good for the house. It's so crazy how we're all supposed to be here in support of the hospital like, well, that's tough for them. They'd have to have more staff. It's like, wait a minute. Are we ever getting who the customer is here? Yeah, exactly.

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How would it serve women? If we were to switch as a general practice to intermittent auscultation or use of a Doppler during labor? And how is its how is it serving hospitals to keep doing continuous electronic fetal monitoring in the face of all this research that shows it isn't better for women, and it isn't improving outcomes?

I'd like to take the second part of that question first, and then we'll get back to how it serves women to increase availability of intermittent auscultation. But how it serves hospital To keep the status quo is first to just keep the status quo, it's hard to change. And this is not a simple change to introduce. So it will take, you know, all the things that any change takes up like a, you know, some champions and some real sort of change management approaches and training of providers and possibly things like getting different kinds of equipment. So, you know, status quo is always more comfortable than change for people. But I think it also kind of slots right in with the overall approach to care where, you know, this is really about getting the baby out by whatever means necessary and making sure it's done safely, so that everybody survives, and, you know, epidurals being the main sort of main offering for pain management, it's like, get her comfortable, get her in bed, keep keep an eye on the baby. And then you know, we'll have a baby when it's time and so I think just just one step above.

Yeah, I mean, it's really no different. I go Yeah, I mean, this is is part of this arc of history that's really been about different ways of kind of controlling women's bodies, strapping them into the bed.

I view this as this understanding that we are there to serve the provider to make their job easy to let them do their job. And if we just turn this around and say they're here to serve us, they need to let us labor. Yeah, we want them there in case we need them. But this is not about us, pleasing them, serving them this whole tone, like here's what I need you to do. I need you to lean back. I need you to know you don't need me to do anything. I need you to keep me safe. As hands off as possible, because that's going to be linked to the safety. Yeah. And you're here to make sure I'm happy at the end of this. Yeah.

Yeah, I think it's right. And we we have a big problem with hospitals not taking that approach and, and fetal monitoring. Again, it's sort of emblematic of this whole thing. They can process more patients through their system if they can keep them on the monitors. They they Sit in, you know, the nurse's station, the provider room and they look at literally like a wall of eight or 10 different monitor strips as if you're keeping all of these people safe and nobody's at the bedside. So it's clearly doing a disservice to the woman.

Yeah. So let's get back to the first part of the question, which is how would it serve women to have intermittent auscultation be more the standard of care? And I think it would, you'd see benefits that we've seen hospitals that have taken a change management approach and have introduced intermittent auscultation in a really proactive way, and sought to change the culture and make sure everybody was trained in the skill. And those hospitals have seen a reduction in their c section rate as a result of those kinds of interventions. But at the biggest thing is it just it changes the experience of labor to have intermittent auscultation instead of these straps around you that keep you sort of immobilized and attached to the bed. Instead, you can decide using your instincts and you know, your labor support people how you want to labor in the bed, out of the bed, in whatever position in the tub. in the shower, all of that opens up when you're not so concerned about this machine that you're connected to.

And all of those things are linked to safer birthing.

Yeah, exactly. That's physiologic care all of that and and be patient with labor and and trust the process, but also be diligent about safety.

There's one line from one of the articles I've published, I think it was the one called better birthing. It's about time.

You gotta get on Tinder. Yeah, yeah, you get it. And in there, I have a line that says something like, this isn't just about vaginal birthing for the joy and gratification of it, though that should not be discounted. A vaginal birth is significantly safer for the mother and baby than a surgical birth. Yeah.

Yeah, that is important for a lot of women personally, but it's important for health and for survival. And for survival, by the way, yes.

Well, and first do no harm. Exactly. continuous monitoring is showing us that it increases harm. Yeah. So it's completely antithethical. It is it is the you know, I do think hopefully that someday we'll look back on this era, which now is a very prolonged protracted era multiple generations now that have had this as the standard of care. But there are other areas of obstetric care that are like so bygone now like the whole Twilight sea sleep thing, there was a period of time where like 90% of babies were pulled out with an episiotomy in a forceps and thank god that's not the case anymore. So hopefully we'll look back at this and be like, what was that about? But we're in it now still.

So what do you recommend? There's a pregnant woman she goes to the hospital and what is it we're really telling her today because this is a lot of information and so overwhelming and what kind of influence does she have? And what is her first choice? What do you what would you recommend?

So I would recommend that the conversation happened before she gets to the hospital and that this is a conversation that happens when you're talking about your you know, birth preferences for Plan whatever you want to say, or even further upstream when you're choosing where to give birth. So I would say the ideal thing is that you are with a provider that truly gives choice and that and that delivers babies in an environment that also delivers choice. So ask questions early. And ideally, you know, if this is important to you, which I think it should be, try to find a hospital or a birth setting that supports it. And I will, I do think it's worth mentioning that you don't even have the option of continuous electronic fetal monitoring, if you're giving birth in the home or birth center setting. You know, they don't have that equipment at home. It's not so it's not in the birth, but there's a lot of stuff in the birth bag, but that's not one of them, which is an immediate plan, which is an immediate thing. And it's a big reason why we see the outcomes that we do with home birth and birth center better and better outcomes as far as natural birth and so on. Yeah,  so and same, same in a birth center.

Same in a birth center. It's actually against the like national accreditation requirements to use fetal monitor and labor. They can use it for like prenatal Testing and things like that. But so first thing you're suggesting is start off at your prenatals. Yeah, find out these are the questions women don't ever ask how do you plan on monitoring the baby's heart rate? And what's the method that you use? What's the typical protocol in this facility that I'm going to be birthing in?

I have a good eye. Just before we move on from that. I think a good way to frame that question for people is what percent of the people who are eligible for intermittent auscultation actually get it in your setting? Even hospitals that I thought were really supportive of that they're like, zero to 20%.

So we can we can help them be honest in their response. Yeah. And then we'll hear how low it is. Yeah, let's say that they seem supportive and a woman is committed to the place where she plans on giving birth. Yeah. What is her first choice because I think even hearing all this she might not be clear on it is Doppler. That was your first recommendation because that is the best supported by the evidence. Yeah, I would recommend if assuming that it's a generally low risk labor. This is not, you know, a preeclampsia situation or a preterm birth that, you know, very early gestation, those kinds of things. You know, I would say go with what your provider is recommending, but assuming you're low risk. Yeah, I would say you should ask for intermittent auscultation. If she gets an epidural, does she have to forego that choice? Yeah. Yeah, then she will go to electronic continuous.

Yeah. And and that should be people should understand. If you're asking for intermittent auscultation, there are going to be things that could change that plan. And that should change your sort of orientation around it as well. Same as if you're a same with pitocin. If you're on pitocin, that's a, that medication is associated with changes in the fetal heart rate. So the fetal monitoring is there to help you make sure that you're not, you know, unsafely using the pitocin. So I think periods of time off the monitor where you can, if particularly ganic, sort of meet the overall eligibility requirements for intermittent auscultation that it certainly should be safe for you to be Off the monitor for 15 minutes or half an hour out of any kind of out of any period of your labor. So don't be afraid to ask like, I just feel like I need to move around or I want to get in the shower for 10 minutes, can I just get off the monitor for a bit and you should be supported in that and you should feel competent to advocate. If you know you meet with skepticism with that, like look, and you can ask some of the language that the folks use them in the hospital is is a category one, category two, or category three tracing. And so category one means everything looks good. So you can ask, is it category one tracing, and if it is, you absolutely should be eligible for some time off the machine if you want. The other option that women should be aware of that sort of a modification of continuous fetal monitoring is what's called telemetry monitor monitoring where they you still have the straps around you for the continuous monitoring and they're still actually continuously monitoring the heart rate but The cords are plugged into a sort of mobile device rather than to a machine that stands there. So you can hook even if you were at like a purse usually, or maybe it goes on an IV pole if you have an IV as well, and you can just walk around the unit and it just beams that information where it needs to go. So it's an option and it's, you know, something that we're seeing incrementally more hospitals adopt.

So no radiation aside, which I'm very uncomfortable with it, correct me if I'm wrong, the only benefit of that method over continuous electronic fetal monitoring is that you have mobility
and but they would be clear, it still is continuous. That's what I was about to say yes, what I was about to say, it's still going to provide that likelihood of false positives. So yeah, as I said,
it doesn't change that. So I you know, I'm just when you, I don't think we talked about this yet, but there's sort of two mechanisms by which electronic fetal monitoring can increase the likelihood of a C section and one I think we did talk about and in great length, which was This false positive problem where like you have a deceleration or some sort of troubling finding, and you don't know, is this baby in trouble? Or is this baby sort of just having some kind of change in their heart rate, that doesn't mean anything. If we tracked our own heart rates all day, every day, we'd see all kinds of weird like variations. So you know, there's all kinds of reasons and the baby might be moving around or taking a nap. So there are things other than the baby is in distress that can be behind that. The other mechanism before we talk more about that is the mobility thing. We know that decreased mobility increases the likelihood of C section and that's probably because of, you know, the way you can open up the hips and help with the alignment of the baby to sort of navigate through the pelvis. It's also movement is highly associated with women's perception of pain and if you are immobilized, you're going to have increased pain which can create a hormonal response that can slow down your labor and then you've got a C section for slow Not for fetal distress, but for slow labor, which was because you couldn't move and respond to your labor or because you're, you know, certain hormones couldn't do their optimal thing is their is their definition of fetal distress.

Fetal distress is a phrase that, you know, I think a lot of people use, and certainly still a lot of clinicians use, but it's not supposed to be used anymore for clinical communication, because it was like other actual it's not well defined, right? We don't know that these heart rate changes mean anything about the baby's actual well being or level of distress or anything like that. So what people are looking for as a sign of a problem in in the fetal heart rate is a deceleration, generally, it needs to be at least 15 beats per minute lower than whatever your baseline is. So if the baby's heart rate is like 140, you're looking for a deceleration that goes down to at least 125 or lower. And then you're also looking or listening for sort of how it returns back to baseline or whether it's sort of continuously goes down. And then like if something persists longer than two minutes, then you're wondering, Is this a Baseline Shift? Or is this what's known as tachycardia, if it's an elevated heart rate, or bradycardia, which is a, you know, abnormally low heart rate so, so they're looking at the rate relative to sort of a normal range, which is generally 120 to 160. So if you've got a baby, that's like hanging around at 175, as their heart rate, it could be normal. But that also could be things like sign of an infection or sign of certain kinds of, you know, issues that you want to address clinically. But there are things you can do before you expedite delivery to sort of get the baby back on board. It's called intrapartum resuscitation, which means during labor, resuscitating the baby You don't have to wait for the baby to come out to resuscitate it, you can change the mom's position. That's a really simple thing. Sometimes babies just kind of leaning on its umbilical cord a little bit or something like that and just sort of loosening up

Pressure cells. It's funny that they call it resuscitation on the last I know, and like, but the other thing is turning off the pitocin giving some more fluids either by mouth or through the IV. There's sort of like simple, relatively kind of conservative things, you can try to resolve some of these things. But, but what So getting back to fetal distress, you know, it doesn't mean anything specific, it makes it sound more serious than it probably is, because most changes that we see are associated with a baby, that's still fine. So I think helping women understand that, you know, they're looking for decelerations, meaning it's sort of a periodic decrease that comes back to baseline, or a sort of pattern that's going down and not coming back, which is the more serious pattern and that would, that would, ultimately if it met certain criteria, become a category three and that's when they're like, it's called We've got to do something now.

Amy, I mentioned internal fetal monitoring earlier. I don't know a lot about it. It makes me very uncomfortable. I once asked a midwife why in God's name were using this thing. And she was like, I know I hear you. But it really works in the case of extreme obesity when they can't otherwise get the heart rate. And then I thought, well, oh, okay, then fine. But we know how everything goes in this industry as soon as they approved things. For one specific high risk case. You're already nodding because you know, the rest of this, they start. It's only a matter of time until they they have a blanket approach and use it on more people. So can you describe what the internal fetal monitoring is?

internal monitoring is kind of what it sounds like, which is using an internal method to monitor the baby's heart rate continuously. The provider does a vaginal exam and then put something that looks like a drinking straw through the through the vagina. That part doesn't hurt. But then there's a little mechanism that they screw, and there's little wire. It's a very tiny little wire, but it screws right into the scalp of the baby's head and it's measuring the heart rate it's able to pick up on the heart rate. So quick thing first one, does it require anatomy, then? Yes. So one intervention always leads to another. Second, the baby is now with certainty going to be born with it breaks the baby's skin, which we're not going to get into today. But that does make vitamin came out a whole other topic for people who are considering what to do with vitamin K. So one intervention always leads to others. So you've explained what it is there's this little electrode that screws into the top layers of the baby's scalp, right? And it does mean that the baby comes out with a little small laceration on their head. And, and it generally heals but of course, like any laceration, it can be a root for infection, it could be, you know, could create some bleeding. So it's not a nine, but it is you know, it's also not The most significant or severe thing you could do, the problem is that it's not very beneficial. And I hear the word overkill. So you asked me to sort of convince you When is it useful and I do think that in cases of extreme obesity, it can be very hard to hear or, particularly for the, with the continuous fetal monitor to listen, you can, by the way, still listen with a Doppler and do intermittent auscultation. And obesity is not necessarily a reason not to use that method. So, but if you're committed to continuous fetal monitoring, and whether it's because of obesity or some or sometimes it's the position of the baby, and you can't hear reliably, it's that's one reason to use it. But I would say that the part of the reason that resonates for me, that's really kind of the only reason that resonates for me is that in some cases, it can help clarify whether a C section is necessary and it can, it can actually give reassurance to the provider that the baby's doing okay?

Because it's more accurate. It's more accurate. So it has its place.

Sure, but not routinely, no not used routinely.

And so one of the things I've been working on with the Institute for a Perinatal Quality Improvement is simulation based training module that's available online for providers that want to strengthen their intermittent auscultation skills and that hospitals and health systems can adopt as their training methods. So. So yeah, we're really hopeful that that will provide some movement in the right direction on this issue.

That's fabulous. So this is a way that all providers and institutions can really learn this skill and get comfortable with it. So yeah, yeah, it's like a direct 30 minute training. So honestly, if you're talking to your provider, and they're like, Oh, my people aren't skilled in that it's something that people can can bring to their attention. So it's the internet, the Institute for Perinatal Quality Improvement, which is perinatal care. org.

So this is great information. This is information for nurses and providers. And where can they find this, again is the Institute for Perinatal Quality Improvement and their website is in the show notes.

What's your final word to women? The final bit of advice that because what I always hear women saying is, they know they're not the medical expert, right? So how can they go in there and influence something so significant as the baby's well being women should feel confident to bring this up with their providers, and they should do it as early as possible in the process. But even if we're talking about in labor, it's absolutely an okay thing to question the use of electronic fetal monitoring and to express a preference and, and a demand for an alternative to that and there might be good reasons why your provider wants to use continuous fetal monitoring either for a period of your labor or for the whole labor, but engage in conversation about that with the confidence that this that intermittent auscultation is absolutely an evidence based and appropriate method of fetal assessment and That it's safe and that you can trust the process and that your feet, your fetal well being is, is enhanced by your ability to move around and have a physiologic labor and avoid some of those interventions that can be part of that cascade of interventions that snowball effect where you're on the monitor, because that's just how they did it. And suddenly, you have an epidural on pitocin because you were stuck in bed Well, hey, by the way, epidural and pitocin can have an effect on the baby's well being and can cause some of these things that this technology is there to, to look for. So back the whole process up, stay off the monitor as much as you can, particularly You know, when you first get there in early labor, and, and just engage in this and don't be afraid it's, it feels very scientific and medical and hard to question, but it's really tea leaves that they're reading and you should understand that and, and be willing to ask for what you want.

And don't be afraid to remind your provider that there professional organization supports this does a great point show right up without positions down and say look, your organization says this is okay. Yeah, so help me out.

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