Running head: CONTINUOUS EFM 1

Continuous Electronic Fetal Monitoring

Taylor Rackey

ENGL 1050

Instructor: J. Aubrey Ridd

Abstract

Continuous electronic fetal monitoring (EFM) is the use of a sensor to interpret a birthing

person’s contractions in conjunction with how the baby’s heartbeat is tolerating the labor with

each tightening of the uterus. EMF requires the use of monitors which are traditionally attached

to cords, that are then placed on the laboring person’s stomach and secured in place by an elastic

band. These cords function by relaying information to a monitor, which in return then prints out

a continuous strip of interpreted data; an intervention that can restrict movement and at times,

require one to remain flat on their backs in a bed. With 89% of hospital labors experiencing some

form of electronic fetal monitoring, there has been a reported dissatisfaction of the outcomes of

birth, resulting from the inability to ambulate during labor, inability to use hydrotherapy due to

equipment, and the increased link between cesarean section due to “non-reassuring fetal heart

tones.” However, this constant monitoring of the fetal heartbeat during labor has been questioned

by those receiving the intervention, in regards to the efficiency, safety, and potential outcomes

regarding cesarean deliveries. The lack of evidence based research has shown that the use of

hands-on auscultation and intermittent monitoring is an appropriate option for those low-risk

clients without pregnancy or labor complications.

Continuous Electronic Fetal Monitoring

Over the course of the average 40 week gestation, pregnant people will most likely

experience their provider regularly auscultating the heartbeat of their unborn baby. This specific

tracking of fetal heart tones helps to determine a client’s baby’s normal baseline, and helps to

detect any abnormal changes in heart rate pattern throughout gestation. During labor, it is

common for this monitoring to occur more often, or even continuously. However, while the

detection of fetal compromise is one of the positive advantages to continuous electronic fetal

monitoring, researchers Sweha, Hacker, and Nuovo (2009) explain that this type of observation

has been shown to include risks, demonstrate inefficiency, and increase the need for surgical

intervention (Sweha, Hacker, & Nuovo, 2009).

In 1958, according to Sweha, Hacker, and Nuovo (2009), electronic fetal heart rate

monitoring (EFM) was introduced at Yale University as a proposed window into the womb with

the ability to monitor the status of a newborn baby before delivery (Sweha, Hacker, Nuovo,

2009). This type of monitoring uses special equipment that may either be placed on the outside

of the laboring person’s abdomen or an internal monitor that is usually attached to the fetus’

head. According to the American College of Obstetricians and Gynecologists (2009), electronic

fetal monitoring was reportedly used among 45% of those laboring in 1980, 62% in 1988, 74%

in 1992, and 85% in 1992 (American College of Obstetricians and Gynecologists, 2009). Today,

researchers Declercq, Sakala, Corry, Applebaum, and Herrlich (2014) report via a survey given

among 2,400 postpartum mothers, that of those interviewed 89% experienced some form of

electronic fetal monitoring during labor and delivery (Declercq, Sakala, Corry, Applebaum, and

Herrlich, 2014).
CONTINUOUS EFM 4

With the use of electronic fetal monitoring during labor, but particularly during labor

admission, researchers Paterno, McElroy, and Regan (2016) found a link between increased rates

of intervention, thus resulting in cesarean section amongst low-risk individuals (Paterno,

McElroy, & Regan, 2016). This reported trigger of interventions have been shown to cascade in

fashion, similarly resembling a domino effect. Paterno, McElroy, and Regan (2016) found that

the largest study of electronic fetal monitoring demonstrated an increased risk of cesarean

section by a reported 81% when monitoring was used, though these findings were not

differentiated between a low-risk or high-risk pregnancy (Paterno, McElroy, & Regan, 2016).

According to a study published by Caughey, Cahill, Guise, and Rouse (2014), the second most

common reason for first-time cesarean sections is “non-reassuring fetal heart tones.” In line with

the American College of Obstetricians and Gynecologists (2015) guidelines, if providers begin to

be concerned with fetal heart rate, care providers may evaluate again with “scalp stimulation,”

which involves touching the fetus’ head and observing fetal heart rate to determine if any

abnormality occurs. The use of “scalp stimulation” may help to lower the rate of preventable

cesarean section when used in conjunction with corrective measures to help resolve abnormal

fetal heart tones, such as positioning (American College of Obstetricians and Gynecologists,

2015).

However, the American College of Obstetricians and Gynecologists (2018) has advised

that the use of either intermittent auscultation or electronic fetal monitoring during a low-risk,

well progressive labor are both appropriate choices to be made with informed consent by the

birthing persons (American College of Obstetricians and Gynecologists, 2018). In a recent

Cochrane review, Alfirevic, Devane, Gyte, and Cuthbert (2017) found evidence amongst 37,000
CONTINUOUS EFM 5

delivering persons that demonstrated the efficiency between continuous electronic fetal

monitoring and intermittent auscultation. Researchers found that overall, there were no

differences between either group in regards to perinatal death, cerebral palsy, cord blood gases,

APGAR scores, or NICU admission; these findings made were shown to be consistent in both

low-risk, and high-risk pregnancies (Alfirevic, Devane, Gyte, & Cuthbert, 2017).

The American College of Obstetricians and Gynecologists (2017) continued to

strengthen their position on the topic of intermittent auscultation of fetal heart tones in a bulletin

that was recently released. It was stated, that while continuous electronic fetal heart monitoring

was introduced to help reduce the rate of perinatal death and cerebral palsy, the widespread use

has not shown any improved outcomes. It is currently recommended that the option of

intermittent auscultation be facilitated for those laboring persons, and that staff be trained on

protocol of handheld doppler use (American College of Obstetricians and Gynecologists, 2017).

In addition, the use of intermittent auscultation of fetal heart rate can help to facilitate the

freedom of movement for the laboring person. Researchers Gupta, Hofmeyr, and Shehmar

(2017) show that those people who choose to birth in an upright position, were 54% less likely to

experience abnormal fetal heart rate patterns during their labor (Gupta, Hofmeyr, & Shehmar,

2017).

Despite the lack of evidence to show the efficacy or safety of electronic fetal monitoring,

this use of technology has grown to be the standard of care in almost all deliveries since being

introduced into the medical field over 60 years ago. With the tools and training of hands-on

intermittent auscultation, low-risk pregnancies are supported by evidence that shows the safety to

be as equal of an option as continuous electronic fetal monitoring. This guideline can help to
CONTINUOUS EFM 6

reduce the need of unnecessary cesarean sections that are determined upon the reasons of

“non-reassuring fetal heart rates,” in addition to providing the laboring person with the option of

free-movement, ambulation, and hydrotherapy. As an evidence-based option, hands on

intermittent auscultation has been shown to reduce the need for intervention that ultimately

results in cesarean section, and demonstrates both the safety and efficiency during labor.
CONTINUOUS EFM 7

References

Alfirevic Z, Devane D, Gyte GML, Cuthbert A. Continuous cardiotocography (CTG) as a form

of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane

Database of Systematic Reviews 2017, Issue 2. Art. No.: CD006066. DOI:

10.1002/14651858.CD006066.pub3

American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 687:

Approaches to limiting intervention during birth. ​Obstetrics & Gynecology,129​(2),

E20-E28. doi:10.1097/aog.0000000000001905

American College of Obstetricians and Gynecologists. (2018, February 05). Fetal Heart Rate

Monitoring During Labor. Retrieved September 7, 2018, from

https://www.acog.org/Patients/FAQs/Fetal-Heart-Rate-Monitoring-During-Labor

American College of Obstetricians and Gynecologists. (2009). ACOG Practice Bulletin No. 106:

Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General

Management Principles. ​Obstetrics & Gynecology,114​(1), 192-202.

doi:10.1097/aog.0b013e3181aef106

American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary

cesarean delivery. ​American Journal of Obstetrics & Gynecology,123(​ 3), 693-711.

doi:10.1097/01.aog.0000444441.04111.1d

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2014). Major Survey

Findings of Listening to Mothers SM III: New Mothers Speak Out: Report of National

Surveys of Women’s Childbearing Experiences Conducted October–December 2012 and

January–April 2013. ​The Journal of Perinatal Education​, ​23​(1), 17–24.

http://doi.org/10.1891/1058-1243.23.1.17

Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women

without epidural anaesthesia. Cochrane Database of Systematic Reviews 2017, Issue 5.

Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub4.

Paterno, M., Mcelroy, K., & Regan, M. (2016). Electronic Fetal Monitoring and Cesarean Birth:

A Scoping Review. ​Birth,43​(4), 277-284. doi:10.1111/birt.12247

Sweha, A., Hacker, T., & Nuovo, J. (1999). Interpretation of the Electronic Fetal Heart Rate

During Labor. ​American Family Physician,1​(59), 2487-2500. Retrieved September 7,

2018, from ​https://www.aafp.org/afp/1999/0501/p2487.html​.