Thursday, July 16, 2009

Fetal Monitoring: Why it will continue

The July 7, 2009 edition of Jane Brody’s superb column, “Personal Health”, in the New York Times , “Updating a standard: fetal monitoring” addresses the use of obstetric ultrasound, fetal heart rate monitoring, and other methods of diagnosis of prenatal fetal vulnerability. She notes that while this was hoped to reduce the risk of cerebral palsy and infant death when it was introduced in the 1970s, it was, said Dr. George Macones of the Washington University in St. Louis, a “…technology… rolled out before we knew whether it worked or not.”

Although she notes that fetal monitoring and has been adopted so widely that it is used in more than 85% of deliveries, Brody notes that:

“…experts report that the use of fetal monitoring has produced both negative and positive results, including these:
· Electronic monitoring has led to a significant increase in both Caesarean deliveries and forceps vaginal deliveries.
· Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit, which has led to soaring costs for malpractice insurance and, in turn, prompted many obstetricians to stop delivering babies.
· Electronic monitoring has not reduced the risk of either cerebral palsy or fetal deaths.”

Pardon me, but which of these are the positives?

I don’t mean to suggest by any means that there is no indication for either prenatal ultrasound or intrapartum fetal monitoring. But it would be nice to have data that it actually achieved the goals – reduction in the rates of cerebral palsy and fetal death – that it was developed and implemented to achieve. Is it possible that it has, but this has not been recognized because, as a result of some unidentified factor or factors, the rates of both would have gone up if not for fetal monitoring? I suppose so, but this is even harder to prove.

What this does demonstrate is how difficult it is to challenge the use of a technology that has become widespread, that makes teleologic sense, and is, in the opinions of most of the experts who use it, a good thing. Once a test or technology has been in widespread use for a long time, it is difficult to subject it to objective assessment. Fetal monitoring is even more difficult than most, involving, as it does, fetuses and newborns. Even though we know that “Electronic monitoring has not reduced the risk of either cerebral palsy or fetal deaths,” to test it would require the use of a comparison group of pregnancies in which babies were randomly assigned to be monitored or not, and outcomes assessed. Who is going to do that when the outcome could be a dead or severely handicapped infant? If “Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit" imagine the lawsuits that would happen when the first baby who was not monitored died or was born with cerebral palsy. Not to mention how you would feel if it was your baby who was not monitored and had a bad outcome. No one is going to do such a test.

So we will continue to use expensive, and invasive technologies, with some potential risk from excess Caesarean sections (although there are many who believe that these are as safe as vaginal deliveries, and that patient preference for one is an adequate indication; this is another discussion), even though we are not sure that it does anything beneficial.

Thus goes medicine.

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