Electronic Fetal Monitoring (EFM)
If recent studies do not support the routine use of EFM, why
is it still so widely used? First, because many nurses and physicians
have not been trained in intermittent auscultation. Second, some believe
that EFM might still be a valuable assessment tool with better guidelines
for interpreting tracings and making management decisions, even though
studies comparing the ability of experts to agree on the interpretation
of an EFM tracing have shown poor interpreter reliability.
Third, physicians may fear that they will be vulnerable to malpractice
lawsuits if they do not use EFM. The impact of changing to intermittent
monitoring on malpractice claims is unknown. Fourth, many hospitals are
not adequately staffed to do intermittent auscultation. In one study,
a university hospital center attempted to use intermittent auscultation
as the primary method of monitoring without increasing the number of staff.
Auscultation was only successfully completed in 31 of 862 patients in
labor with viable fetuses.
- American Academy of Family Physicians, May 1, 1999
A conversation I had a few years ago with Dr. John Ott, the author of the book Health and Light, shed some light on non-advancing labor where
the mother and/or baby is hooked up to a monitor. Dr. Ott's research in
the color spectrum wavelengths led to a curiosity about the effects of
electrical fields on the human body. His work led to the first commercially
available full-spectrum shielded fluorescent lighting. He told me that
susceptible persons are greatly weakened by artificial energy fields.
Dr. Ott predicted that the number of cesareans would increase in hospitals
using fetal monitors. But his reasons were different than most would think.
He claimed that when a maternal or fetal monitor is hooked up, its energy
field makes muscles weak for both baby and mother. And of course, the
uterus is a muscle. Add to this all the electronic equipment in the typical
delivery room, plus all the voltage-carrying conduits in the hospital.
- Judy Ritchie, excerpted from her article in The
Birthkit No. 23, Autumn 1999
The issue of whether EFM reduces brain damage to the offspring received
its biggest surprise with the publication of a randomised clinical trial
which assessed the neurological development at 18 months of age of 2 samples
of children, one group born prematurely whose heart rates were monitored
electronically during birth and compared with the other group of children
born prematurely whose heart rates during birth were monitored by auscultation.
The incidence of cerebral palsy was 20% in the EFM group and 8% in the
group that was monitored by auscultation. That the use of EFM should possibly
increase the incidence of cerebral palsy may be the result of birth attendants
focusing on the monitor rather than the overall condition of the woman
and baby. The authors admitted to being unprepared for such a negative
finding and a flurry of letters in subsequent issues of the same journal
indicated that many other resist data which is against their beliefs....The
fact that the cerebral palsy rates have remained the same for the past
30 years in spite of widespread EFM is further evidence of the lack of
efficacy of EFM to reduce neurological sequelae. These results echo those
of the other randomized controlled trials: There is no scientific evidence
that routine EFM during labour improves the condition of the baby at birth
or reduces the possibility of brain damage.
- Marsden Wagner, MD, Pursuing
the Birth Machine, Ace Graphics 1994
Doctors tell us that EFM protects against malpractice suits or hospitals
have too few nurses to auscultate often enough (Ob Gyn News 1988). The
malpractice argument rests on beliefs that tracings are valuable courtroom
evidence and that not using EFM renders doctors liable because it is standard
practice. As to the first, Sandmire (Obstet Gynecol 1990) trenchantly
observes that a tracing "leaves a permanent record for hindsight
interpretation by expert witnesses" who will claim that mild deviations
indicate fetal distress. As for the liability issue, Gilfax (Am J Law
Medicine 1984) reviewed the law pertaining to EFM and informed consent
and concluded that using auscultation over EFM did not render a doctor
liable because of the abundant evidence that auscultation is equally good.
Indeed, Gilfix continued, informed consent demands that women be informed
of risks and benefits of proposed tests and treatments, which would mean
a duty to inform women that EFM has not been shown to improve outcomes
but increases operative delivery rates. Finally, "too few nurses
to auscultate" really means too few nurses to provide optimum care.
Gilfix thinks doctors may be obliged to inform women of this too.
Meanwhile, what about "first do no harm"? Both of these defenses
of EFM are predicated on benefits to doctors and hospitals at the expense
of mothers and babies.
Judith Lumley (Birth 1982), quoting J.B. McKinley, paints yet a darker
picture of the forces driving EFM: "The success of an innovation
has little to do with its intrinsic worth...but is dependent upon the
power of the interests that sponsor and maintain it....The power of such
interests is also evident in their ability to impede the development of
alternative practices...that could conceivably threaten an activity in
which there is already considerable investment. The "need for universal
EFM legitimates so many other contentious decisions on the place, style
and management of labor that it will not be discarded in favor of [auscultation]
but only displaced when another new, equally unevaluated procedure arrives
on the obstetric scene." This would explain why only one study has
looked at whether auscultation was feasible in a big, busy unit--finding,
by the way, that it was (Sandmire).
- Henci Goer, Obstetric
Myths Versus Research Realities, Bergin & Garvey, 1995
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Midwifery Today's Online Forum
"I want to start a movement that asks state legislatures
and the federal government to mandate that insurance companies pay for
homebirth. The way I see it, if they can make insurance companies pay
for birth control which is considered a "reproductive right,"
then homebirth should also be a reproductive right. Besides, it will save
the insurance companies money for every homebirth.
Do you think I'm nuts? Do you think this could happen?
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week
Q: When should the infant's cord be cut, before or
after the infant is breathing well on its own? Why?
- D. Young
Send your responses to:
Question of the Week Responses
Q: How important and under what conditions is a sterile
field a primary concern in delivery?
- Karen Stokka
A: Although many circumstances come to mind, both hospital and
home, home wins out for me (particularly some homes). Some people have
their homes very tidy for laboring but I have been surprised a few times
by dirty homes that the clutter had simply been removed from. One that
comes to mind is a call for help I received from a laboring couple (almost
strangers, I hadn't seen them prenatally) who had two clean diapers, a
semi-clean towel, and a sleeping bag on which to birth, and that's all!
Yes, I was thankful for the sterile field that night!
A: Since birth is not a sterile procedure, a sterile field doesn't
make much sense. Everything is moving down and out of the vagina, and
the vagina is clean, not sterile. Therefore birth is a clean process.
Starting out with sterile equipment is not a bad idea. But to cover a
woman in blue and paint her with Betadine is in my opinion unnecessary.
Betadine is very harsh on open tissue too. Using warm washcloths and keeping
your equipment clean should be sufficient.
- Molly, CNM
Q: What is the longest you have seen from full dilation to the
beginning of pushing--or to the birth of a baby? What were the outcomes??
- Nancy Wainer
A: With the birth of my fifth child, I went into the birthing
center at 9 pm dilated to 5 cm. By 1 a.m. I was dilated to 10 and the
midwife could stretch the cervix over the baby's entire head (my water
hadn't broken yet). I had absolutely no urge to push, and I chose to wait
to see what would happen. By 8 the next morning I was still fully dilated
and still had no trace of an urge to push although I had tried numerous
things during the night (one thing I wish I had tried was evening primrose
oil on the cervix). The problem was that I was becoming exhausted and
I knew I would need either some sort of pain reliever/sleep inducer to
get my energy back or I would need to try to have my water broken to move
things along. I knew if I didn't push soon, I would be so depleted by
the time it came to push I would be out of energy. After my membranes
were ruptured I went through another, more intense, transition and pushed
the baby out. His arm was up and over his head with the cord wrapped around
his body and shoulder, so perhaps this is why he didn't begin to descend
through the birth canal. Perhaps the lack of a head pushing the membranes
against the cervix made a cushion so that my urge to push was not triggered.
My healthy, perfect, 7 pound 6 ounce boy was born at 10:30 am.
A: Why do we think 2-3 hours is the max for first-time moms? I
feel the most important questions are 1) How is the baby doing? Are there
still reassuring signs that he/she is doing well and can continue to do
so for a while? 2) How is the mom doing? How is her morale? Does she have
the strength to continue? Does she need to rest for a while? 3) How is
the father feeling about how things are going? 4) Have I honestly and
completely let them know all their options?
This summer I had a first-time (homebirth) mom who pushed 6 1/2 hours.
She was a very slender mom with a marginal pelvis, but in excellent physical
shape. At 2 weeks postdates she went into labor and her 1st stage was
less than 6 hours. The baby sounded great, and we set up quickly for delivery.
One hour went to 2, then 3. Vitals were still excellent and she was making
progress, although very, very slowly. We kept cheering her on, but didn't
pressure her. I was very honest with her and acknowledged that, yes, this
was longer than most, but she and the baby were doing great. I also gave
them the option of going into the hospital (where we have a great backup),
which they declined. At 5 hours we could barely see the top of the head,
at which point I said, "In 30 minutes we are going to reevaluate.
I know you can't do this all day and if you haven't made good progress,
we will go in." I felt this would either give her the determination
to finish, or if she really deep down wanted to go into the hospital she
would give up pushing at that point. It worked and she made great progress
and finally delivered a baby with the longest cone-shaped head I have
ever seen! He also weighed 9 lbs. 2 oz. I believe it took all 6 1/2 hours
to allow that baby to mold through her pelvis. I was hoping that the mom
wouldn't look back on this and feel like she had been forced to endure
an awful event. Instead, both parents are incredibly grateful, feeling
they would have had a c-sec otherwise.
Remember, the key is not necessarily time, but how are mom and baby doing
and how long can they keep this up.
- Wendy L. Lamp, CPM
A: I served a young first-time birthing couple who dilated to
10 with a little lip. We had everything set up to catch a baby, but everything
stopped. I stayed around for a few hours. Mom was up and busy part of
this time-she walked in the yard, took a warm shower, took blue cohosh.
Nothing. Her waters remained intact. I lived 5 minutes away, so I went
home. I talked with the mom often to be sure all was well. The 8th day
I got my call. The mom was in the shower and I arrived just in time to
catch the baby, a beautiful little boy. In the 21 years of attending births
I have been with others who have done this as well. They were always farther
away so I was not as comfortable leaving so I left the decision to the
parents. I have never seen a problem with just waiting as long as the
waters were intact.
Coming E-News Themes
1. GBS: I'm curious how other midwives counsel their
clients about GBS. Do you have any new information that would make it
easier to give better and clearer informed consent to clients? Do you have tricks in case the culture comes back positive?
- A.W. (Issue 2:43, Oct. 25)
2. DOULAS: If a birthing woman has good midwifery care,
why might she also benefit from having a doula attend her birth? (Issue
2:44, Nov. 1)
Send your responses to:
Know a strong woman? Helping empower one? If you haven't already done
so, please forward this issue of Midwifery Today E-News to one or two
of your friends or business associates. Thanks so much!
I believe Mary Bove was misquoted in Issue 2:32 concerning
flavinoids for varicosities. The proper Latin name of bilberry is vaccinium,
not caccinium. Women should be advised to use the proper form of this
herb: Vaccinium leaf lowers blood sugar by suppressing the catabolism
and release of glucose from the liver. Not a good idea for pregnancy when
blood sugar is already so altered! The form with the flavinoids is the
berry; however, most herbalists believe this is one of a handful of herbs
that should be standardized in order to be effective. Standardized vaccinium
is quite expensive. Why not use wise woman healing instead by encouraging
mothers to nourish themselves with foods rich in flavinoids? These include
the inner peel of citrus fruits, apricots, blueberries, broccoli, cherries,
currents, grapes, kale, kasha, peppers, prunes, raspberries, and rosehips.
About vitamin K (Issue 2:39): This fat-soluble vitamin is
vital for the production of prothrombin, a blood protein involved in clotting.
It has no effect on circulation, but deficiencies may lead to abnormal
or excessive bleeding. I have not found that tomatoes are a particularly
rich source. Instead try alfalfa, nettles, kelp, and dark, leafy greens.
Most of the Vitamin K we need is produced by our gut flora, yet another
reason to beware antibiotics! Large doses of the synthetic form can actually
be toxic to a newborn.
In response to comments about saturated fats [Issue 2:39]:
Our ancestors and people in traditional societies did consume saturated
fats in the form of animal meats. However their meat was all "free-range"
and not fattened with grains, so the proportion of saturated fat was much
lower than in most commercially available meats found at the grocery store.
In addition, they ate quite a different overall ratio of fats than we
eat now, with much higher Omega-3 consumption. Especially important, they
did not have access to ANY trans-fats or refined/oxidized/potentially
rancid fats, which are more typical of the "McDonalds meal"
than just saturated fats. Animal fats do not interfere with our metabolism
of Essential Fatty Acids in the way that processed vegetable oils and
margarine do. Saturated fats are not the evil entities we have been led
to believe. They only potentially cause problems if we are depleted of
micronutients, antioxidants, and EFAs. Standard American Diet, anyone?
(For more information on traditional people's diets, Weston Price is a
superb author. See Udo Erasmus for information on fat biochemistry. A
good general introduction to both subjects can be found in Paul Bergner's
Power of Minerals.")
- Adrienne Leeds
Although recently arrested Illinois midwife Yvonne Cryns had
been ordered to stop practicing midwifery, the state had no legal right
to do so, according to several Illinois members of the Midwives Alliance
of North America (MANA). "There is no Illinois law which either prohibits
or regulates the practice of direct-entry midwifery, and there hasn't
been since 1965," states Valerie Vickerman Morris of Elgin, a direct-entry
midwife since 1983. "In fact, Illinois does not license midwives
of any kind. Certified nurse-midwives work under the Nurse Practice Act
as advanced practice nurses, and are certified by the American College
of Nurse-Midwives. The State of Illinois does not issue 'midwife licenses'."
Morris has received two cease and desist orders from the Illinois Department
of Professional Regulation (IDPR), which she is appealing in Cook County
Circuit Court. "We support the right of parents in this state to
choose a direct-entry midwife for their birth, as well as their need and
right to receive qualified care from a well-trained professional,"
said Morris. "Illinois midwives have been trying for the last twenty
years to pass legislation which would provide for midwifery licensure."
In the last three years, nine cease and desist orders have been issued
by IDPR to eight Illinois midwives. Cryns received an order to cease and
desist the unlicensed practice of nursing and midwifery in April.
"Midwife-attended homebirth has been repeatedly shown to be a safe
option for healthy, low-risk women," Morris continued, "and
despite IDPR pronouncements to the contrary, it remains an option that
is not prohibited by the Medical Practice Act, the Nurse Practice Act,
or any other Illinois statute."
Contacts: Valerie Vickerman Morris RN, 847-931-5222; Attorney Kenneth A. Runes, 847-934-0060.
As an independent midwife in New Zealand, I have cared for
a woman with severe hyperemesis. She had lost her first baby at 16 weeks
as a direct result of hyperemesis as she had no medication to help her
situation. With the next pregnancy the same problem occurred and she was
admitted to hospital three times in the first trimester for rehydration
and was put on the antiemetic prochloperazine maleate (stemetil) 10 mg
3x daily. This dose varied throughout the pregnancy according to her need
but it was the only thing that worked. She also had tried all the remedies
that normally would have worked. She tried at times through the pregnancy
to stop the medication but had to continue right up until she delivered
a healthy baby girl.
I am starting a reflexology diploma so I can apply it to my
midwifery practice, my ultimate aim being to provide more choice with
less risk for pain relief in labour. I wonder whether any practising midwives
use reflexology in their practice? I would like to know of your experiences,
the indications and contraindications, (we've been told as reflexology
students we should not practice on anyone less than 24/40) and if anyone
could recommend a reading/resource list.
My understanding of heartburn is that the same hormones that make your
joints more flexible to make the birth easier, also relaxes the round
muscle that closes your stomach. Two simple remedies can help: sleep with
one or two more pillows than you are used to; it will prevent the content
of the stomach from burning your esophagus. And 1/2 hour before each meal
take one or two tablets of slippery-elm; this will coat and protect the
area that gets burned from the acidity of the stomach content.
I hope a big grain of salt was taken with many of the interesting historical
references to birth rituals.
I'd also suggest people read up on the causes of obstetric fistula for
which Dr. Sims invented his speculum. Neglected obstructed labour in the
1800s was the prime cause for this instrument's development.
- Phil Watters
Editor's note: Readers may have been taken aback by some of the
practices mentioned in Issue 41. But further study often reveals interesting
explanations for their efficacy. Take, for example, the practice in Bihar,
India, of having the woman whose labor is not progressing drink water
in which her mother-in-law's big toe had been dipped. Author and researcher
Janet Chawla explains: "In Ayurveda the "nadi" for "pran
vayu" (which is understood to be a carrier of knowledge and experience)
exits the body via the big toes--thus the custom of touching elders' feet
allows for the transmission of this knowledge to those of lesser knowledge/experience.
It is logical to assume, thus, that the mapping of the body implicit in
the mother-in-law's big toe ritual is similar to the mapping of Ayurvedic
understanding. The social hierarchy of mother-in-law/daughter-in-law is
perhaps encoded in this rite, transmitting the respected female elder's
permission for the birth to proceed, granting the status of maternity
to the "bahu," but at the same time asserting her authority
and primacy. Certainly the folk understanding of the inner terrain of the body is closer to that of Ayurveda than it is to the anatomy and physiology
of allopathic medicine."
In my Italian family, no one is to point anything sharp (needles, scissors,
even fingers) toward a pregnant woman's belly because the placenta may
I am a self-study student from Texas, and I cannot express how Midwifery Today has made a difference in my education. I am on a limited budget
and have been unable to afford a subscription, so I borrow any and every
MT I can get my hands on. This has become one of the single greatest resources
in my educational process. I am so grateful to all the midwives who have
given their knowledge so we can learn. I have truly learned more from
devouring MT than any text on the market. I just read the latest issue,
and again you have done a brilliant job. I have almost finished my training
and hope in the summer of 2001 to take the NARM exam. All the articles
are written by real midwives who practice midwifery every day. If they
write about it I know it works, and I can use it as a true frame of reference.
Thank you so much!
- Dianne Bolton
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"Prenatal care consists of everything a woman does for herself during
pregnancy, punctuated by a series of visits with you," says midwife
and author Anne Frye.
I disagree. Prenatal care is care provided by a professional, be it doctor,
nurse or midwife. Proper prenatal care helps the mother select a good
diet and exercise suitable for her current state of pregnancy, punctuated
with a series of screenings to determine if all is continuing normally.
Additionally, questions the mother may have regarding anything to do with
her pregnancy contributes to the mental portion of prenatal care. Unless
a mother-to-be is a professional herself doing all the regular screenings,
I don't think she is justified in saying that she had prenatal care. Few
mothers can order the screenings themselves and interpret them correctly
Why would evening primrose be necessary in a first-time delivery or a
VBAC? Why would my midwife encourage its use for my VBAC and my sister's
doctor discourage its use for her first-time delivery? Are there any risks
or dangers involved? What are the benefits?
I am studying for the NARM exam and am looking for the following used
midwifery textbooks: Practical
Skills Guide for Midwifery, Understanding
Diagnostic Tests in the Childbearing Year (Frye), Healing
Passage (Frye), Mayes
Midwifery (Sweet), Textbook
for Midwives (Myles), Human
Labor and Birth (Oxorne & Foote), Williams Obstetrics, A New View
of a Woman's Body (Gage), Maternal Newborn Nursing: Family Centered Approach
If you would like to sell (or donate) any of these books, I would really
Reply to: email@example.com
Greetings from Fortaleza, Brazil! As you may know, in Brazil, a country
where midwifery does not exist as an established profession, the cesarian
section rate in most private hospitals is as high as 90%, whilst
poor women give birth in degrading conditions in the world's most crowded
What you may not know is that in the same country, a number of initiatives
have been created since the 1980s that attempt to recover human values
in childbirth, a movement known as the "humanization of childbirth."
On November 2, 3 and 4 midwives and others interested in maternity care
from all over the world will gather at the International Conference on the Humanization of Childbirth to promote humanized childbirth.
Contact the Conference Secretariat at +55 85 246 4302/246 0232, by fax
at: +55 85 246 2697, e-mail: firstname.lastname@example.org,
WWW at www.humanization.org
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