Interesting article: Fetal Monitoring Often Tips Scales Toward Cesarean

[brittone2]

http://www.medpagetoday.com/MeetingCoverage/SMFM/37361?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&xid=NL_DHE_2013-02-15&eun=g352182d0r&userid=352182&[email protected]&mu_id=5345887

From the above:
-about a third of women have a first cesarean section based on "nonreassuring" fetal heart patterns seen with the electronic monitors despite almost no evidence for benefit, Alison G. Cahill, MD, of Washington University in St. Louis, explained during a symposium.

-of the 32% of primary cesareans done with fetal heart tracings as an indication, only a tiny portion reach the category III level at which the National Institute of Child Health and Human Development recommends cesarean delivery or operative delivery.Most are taken to surgery over an indeterminate category II pattern, Cahill noted.

It will be interesting to see if the idea of a "command center" where only certain tracings are called down to the bedside ever gets studied. Hopefully they'll continue to study which types of category II tracings are problematic vs. within the range of normal.

I imagine the liability concerns will have things continuing as they are with routine EFM, but I don't know.

[swissair81]

The problem is that studies consider negative happenings as minor population statistics. For the people of the 2 or 5%, these studies are not particularly reassuring. In light of our litiginous society, we will still go to the bedside for every slightly adverse tracing. What we should do is require scalp stim and scalp pH for every potential c/s to prove it is necessary.

[TxCat]

The problem is that studies consider negative happenings as minor population statistics. For the people of the 2 or 5%, these studies are not particularly reassuring. In light of our litiginous society, we will still go to the bedside for every slightly adverse tracing. What we should do is require scalp stim and scalp pH for every potential c/s to prove it is necessary.

Most studies looking at correlation of fetal scalp pH and correlation with fetal outcomes, as well as ease of obtaining good fetal scalp pH readings, have been very problematic. It was hoped that this might become the silver bullet, but it's not turning out that way.

Most people who practice in obstetrics will readily admit that continuous electronic fetal heart monitoring is a total boondoggle. It's practice was instituted without any evidence based studies and while the intention was admirable, to reduce bad outcomes and the incidence of cases such as cerebral palsy, it's really just raised the c-section rate. Here's the problem though - its nearly impossible to do any significant prospective study in the pregnant population - the safety hoops are endless, and then there is the problem of recruitment. As far as daily practice, with regard to interpreting heart tracings, certainly there is concern about litigation, but the more real fear of a bad outcome for mom or baby. It's devastating when it happens for all of the healthcare team members, because you can never shake the second-guessing and what ifs. So I truly feel for my OB colleagues because if you get a bad outcome once, that stays with you forever, and you vow to change your practice to try to avoid that ever again.

[AngB]

In my infant loss support group, I just met a woman whose baby had a funky heart rate while she was in labor (would go way up, then have a decel, etc.). The baby's heart gave out right before she was pushed out. It took them 18 minutes to resuscitate the baby and by then she had no brain activity. They tried the newish brain cooling stuff, but it didn't work. I'm certain she would have GLADLY had an 'unnecessary' c-section vs. a dead baby. This was a few months ago, in a major level III NICU baby factory type hospital.

For all the unnecessary c-sections, if it saves one baby that otherwise would have died, I'm ok with that. And I don't think they can say exactly, even in hindsight, "oh that baby could have survived labor just fine" because if their HR is doing funky stuff for the monitors, it's hard to say that.

[brittone2]

In my infant loss support group, I just met a woman whose baby had a funky heart rate while she was in labor (would go way up, then have a decel, etc.). The baby's heart gave out right before she was pushed out. It took them 18 minutes to resuscitate the baby and by then she had no brain activity. They tried the newish brain cooling stuff, but it didn't work. I'm certain she would have GLADLY had an 'unnecessary' c-section vs. a dead baby. This was a few months ago, in a major level III NICU baby factory type hospital.

For all the unnecessary c-sections, if it saves one baby that otherwise would have died, I'm ok with that. And I don't think they can say exactly, even in hindsight, "oh that baby could have survived labor just fine" because if their HR is doing funky stuff for the monitors, it's hard to say that.

Well, I think the issue isn't that they never save babies, or that they have no purpose at all in L&D. My intent in posting the link isn't to second guess whether any one individual's c/s was "necessary" or "unnecessary." I've worked with my share of children who experienced birth trauma, CP, etc. and I realize those things can and do happen, and it is horrible when it does.

I think the issue is that there are also babies who undergo issues resulting from unneeded c/s, and that has very real risks to baby and mom as well, especially on a population level. I think it is impossible (eta: and not productive) to judge any one individual's situation, but I do think it is important for researchers to continue to study this on a broader population level. Additionally, an "unnecessary" (I don't like that term but whatever...) primary c/s can create problems for future pregnancies, and can affect the health and risk of mortality of mom and baby in those future pregnancies as well.

Yes, most c/s that may have been "unnecessary" (but who knows?) end up just fine. I do think it is important that research continues because those unnecessary primary c/s do have risks as well, including respiratory issues and other complications that can and do result in deaths as the result of the c/s. And of course, then there's the impact of that first c/s on the health of future pregnancies. Again, most of the time it is fine, but it is a real risk for some women and babies.

I'm so sorry for that mom's loss. But that doesn't erase that some babies and mothers have also been lost as the result of unnecessary c/s too. My point isn't that there shouldn't be EFM of any type, but obviously it is good that they are continuing to look into how to best manage the data in order to get safer outcomes.

[Katigre]

I'm certain she would have GLADLY had an 'unnecessary' c-section vs. a dead baby.
For all the unnecessary c-sections, if it saves one baby that otherwise would have died, I'm ok with that. And I don't think they can say exactly, even in hindsight, "oh that baby could have survived labor just fine" because if their HR is doing funky stuff for the monitors, it's hard to say that.
But unnecessary csections ALSO cost the lives of mothers and babies. More csections (above 12%ish of all births) means more maternal death - period.

If a csections were a guarantee of health then we'd abandon natural births altogether. But they're not always - and deciding when they're warranted and when they're risky overkill is far from clear with the tools available to us. Continuous fetal monitoring is one such double edged sword.

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[scrooks]

But unnecessary csections ALSO cost the lives of mothers and babies. More csections (above 12%ish of all births) means more maternal death - period.

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I guess I just have a question....I'm not necessarily trying to take either side but do the stats on c/s deaths include those deaths that are from underlying conditions that could have (or very likely would have) resulted in death whether or not a c/s was performed? It seems to me in some cases c/s are used when the health of the mom maybe more delicate which subsequently causes a higher death rate for c/sections....

[Katigre]

I guess I just have a question....I'm not necessarily trying to take either side but do the stats on c/s deaths include those deaths that are from underlying conditions that could have (or very likely would have) resulted in death whether or not a c/s was performed? It seems to me in some cases c/s are used when the health of the mom maybe more delicate which subsequently causes a higher death rate for c/sections....
Some of the complications are from the surgery : infection and blood clots well as hemorrhage.

Another problem is how the risks to mom increase with subsequent pregnancies. Conditions like placental accreta are VERY serious and impact mom's with their subsequent pregnancies after cesarean whew the placenta grows into the scar tissue.


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[brittone2]

It is pretty well documented that primary c/s does have its own set of risks. Certainly it is a necessary option, and I think we're all thankful it is available. But yes, overuse has its own set of risks, not only to mom and baby in that pregnancy, but also in future pregnancies. I am absolutely sympathetic to the fact that it can be a very tough decision to make for an individual OB. However, on a population level we can't ignore that unnecessary c/s are happening (WHO, NIH, etc. acknowledge this), and that it does have an impact on the health of moms and babies, and future pregnancies.

These are just some of the issues:
http://www.ncbi.nlm.nih.gov/pubmed/21860302
http://www.ncbi.nlm.nih.gov/pubmed/23009961
http://www.ncbi.nlm.nih.gov/pubmed/23090464

[KLD313]

I had a c-section with DD. With DS I tried everything to avoid another one. I had to have many NST's and I was there forever because my DS never traced right. He would turn or whatever. A few times I had to go for BPP's. My midwife was afraid that he wouldn't track well during labor and that it would make the hospital push for a section. If you didn't have a previous CS the hospital would allow intermittent monitoring but with a prior you had to be continuously monitored.

I did end up with another CS but not because of the monitoring. Ironically, he tracked perfectly during labor.