How Electronic Fetal Monitoring Can Prevent Cerebral Palsy

Prenatal Care and Childbirth

Nurse setting up fetal heart monitor on pregnant woman

Howard A. Janet
CPFN Legal Advisor

Knowledge Is Power

As the parent of a child who suffers from cerebral palsy (CP), you are well aware of this old adage. That’s why you spend countless hours reading, searching the Web and poring over new sources of information about CP, its symptoms and advances in treatment. You tirelessly seek any shred of knowledge that may help maximize your child’s abilities and strength, improve his health and enhance his quality of life. When it comes to your child’s wellbeing, you don’t rely solely on your doctor; you are proactive. You do your own homework.

You recognize that there is more new and emerging information about cerebral palsy available than any one treating physician may know. And you understand that your doctor is focused on treating patients. He has only a limited amount of time to spend with you.

So, you burn the midnight oil. You leave no stone unturned.

The intent of this article is to help parents better understand issues surrounding one cause of cerebral palsy – oxygen deprivation during labor (intrapartum asphyxia), which can lead to brain injury. A lot of conflicting information is available about the prevalence of intrapartum asphyxia, how to prevent it and how to lower the risks of it occurring in future pregnancies.

There is a myth that intrapartum asphyxia is rare—a myth that has its roots in outdated research that has been disproved in recent years. And there is a second myth that electronic fetal monitoring (EFM) is an unreliable way to assess the well-being of fetuses during labor, and therefore, it doesn’t help reduce the incidence of CP. The research and opinions of many respected physicians tell a different story.

By learning more about EFM, parents can make an informed judgment about whether this technique was used properly during the labor and delivery of their own child. More importantly, those armed with this information can take knowledgeable, proactive steps to not only ensure the safe, healthy delivery of their next baby, but may also help ensure the baby of a friend or acquaintance has the same chance of good health.

Let me be clear: CP can be prevented in many births. We don’t have to wait for medical science to ﬁnd a way to prevent every CP occurrence. We can save many babies from developing this heartbreaking, debilitating condition today. Brain injuries during the intrapartum period that result from decreased oxygenated blood flow to the fetus often can be detected through accurate interpretation of EFM tracings and prevented by timely, appropriate action.

A problematic EFM pattern may require something as simple as giving intravenous fluids or oxygen to the mother, turning or repositioning her, discontinuing pushing, or stopping the administration of Pitocin (intrauterine resuscitative measures). On the other hand, certain EFM tracings may require more serious action, including an emergency Caesarean section.

Generally speaking, the public is unaware of electronic fetal monitoring issues. Soon-to-be parents devour every bit of information they can find about prenatal nutrition, exercise, birthing centers and labor techniques. However, they often have no understanding of the critical role that electronic fetal monitoring can play in the outcome of their delivery.

Just as parents are encouraged to enroll in Lamaze-type classes to learn how to ease the pain of labor and delivery, every parent also should be schooled in the meaning of certain EFM patterns. It is important for parents to know enough about EFM to be aware of the right questions to ask their obstetrician and labor room nurses about their baby’s EFM tracings and how they relate to events that may occur during labor.

Remember, knowledge is power.

Research Barriers

Generally, though, parents don’t seek, nor are they encouraged to learn this kind of information. When it comes to getting the facts about how doctors and nurses use EFM tracings to monitor fetuses during labor and delivery, and the proper responses to those tracings, parents are encouraged to rely on their healthcare providers.

Unfortunately, healthcare providers themselves are divided on this issue, the result being that a lot of conflicting information – even misinformation – is generated. For example, even ofﬁcial obstetrical documents, such as Practice Bulletin No. 62, published by the American College of Obstetricians and Gynecologists (ACOG), contain inaccurate data and downplay the prevalence of cerebral palsy caused by intrapartum asphyxia, which in some instances is preventable.(1)

In fact, so much outdated research data and distorted information is in circulation that it drowns out the voices of anyone who tries to call attention to data that proves EFM can prevent many cases of cerebral palsy. The truth about EFM is so buried in misleading medical literature that parents seeking an accurate, complete picture must dig deep to ﬁnd it.

Why the Confusion About EFM?

Popularized in the 1970s, EFM is a method for examining the condition of an unborn infant in the uterus by noting unusual patterns in its heart rate. EFM is a dependable measure of how the unborn child is withstanding the changes in environment and stimuli that it experiences during the birthing process. By monitoring the baby’s heart rate and graphing it on strips of paper, called “tracings,” doctors and labor room nurses have a real-time, and an overall, picture of the baby’s condition throughout labor.

Statistics compiled for the year 2002 indicate that EFM was used to monitor 85 percent of all births in United States hospitals. Many of the other 15 percent involved natural childbirth, where the parents opted to use midwives or to deliver their children in birthing centers. Even in natural settings, however, when a troublesome heart rate pattern develops during labor, those assisting with the birth usually move the mother immediately to a facility where EFM is available.

So, why would the medical community refute the reliability of EFM in publications and statements, while using it so widely and consistently?

Unfortunately, many in the medical ﬁeld have an agenda that focuses more on shielding themselves or their colleagues from accountability than with educating patients and reducing the risk of CP.

Clearly, their concerns are misguided. These physicians and organizations should be a beacon of truth and knowledge for their patients. They should be a source of facts for patients and, indeed, a fountainhead of leading-edge information for parents who want to be proactive in their health care.

But a growing number of well-credentialed obstetricians, labor and delivery nurses, and midwives are speaking up. These preeminent members of the medical community, who use EFM every day to assess the well-being of fetuses during labor, say that EFM is viable and effective in reducing the incidence of CP, and fetal mortality as well. The efficacy of EFM is demonstrated further by the continuous increase in the percentage of births in which it is used: 45 in 1980, 62 in 1988, 74 in 1992, and 85 in 2002.(2)

Fact Versus Fiction

Parents must realize that their quest for knowledge about their children’s health care should start before the labor and delivery process. When you undertake your research, you will be astounded by the misinformation you will ﬁnd. For instance:

Misinformation: Children rarely develop CP from asphyxial injuries to the brain during the intrapartum period. The American College of Obstetricians and Gynecologists claims that several studies support the conclusion that only four percent of CP results solely from asphyxia during labor.(3)

Reality: The studies on which ACOG relied are inferior and unreliable. Even if the scope of the inquiry were limited to instances of CP where intrapartum asphyxia is the sole cause as opposed to the primary cause, the actual percentage would be approximately three times greater.(4) According to Joseph J. Volpe, M.D., a Harvard professor and Neurologist-in-Chief at Boston’s Children’s Hospital, if all term infants are considered, the percentage of children who develop CP from intrapartum asphyxia is “approximately 12 to 23 percent” which equates to “a large absolute number of infants.”(5) Dr. Volpe concludes, further, that the “tendency in the medical profession to deny the importance or even the existence of intrapartum brain injury” is “particularly unfortunate,” and may well be impairing progress in CP prevention.

Misinformation: Electronic fetal monitoring has not reduced the number of children who develop cerebral palsy.(6)

Reality: This false claim fails to take into account today’s enhanced survival rates of premature infants. Nationally renowned maternal-fetal medicine specialist, Richard H. Paul, M.D. (who is one of the pioneers in EFM), and other experts have testiﬁed to the inaccuracy of this claim in malpractice trials brought by parents who contend that their children’s cerebral palsy was caused by medical error.(7)

In the days before EFM and recent medical advancements, doctors lacked the expertise and technology to save many premature babies; generally, efforts made to save infants weighing less than three pounds were tragically unsuccessful. Today, infants of a pound or less receive active treatment and life support, and routinely survive. These premature infants represent a substantial number of the children born with CP. Yet, despite the addition of these preemies to the survival pool, the total number of infants born with CP has remained constant.

If the number of surviving premature babies who develop CP has significantly increased, but the total number of cases of CP remains the same, then the number of full-term infants that have CP must have declined. Many infants who otherwise might have developed CP have escaped an unfortunate fate because EFM was used properly during labor and delivery.

Misinformation: Obstetricians disagree so widely in their interpretation of EFM tracings that standards for interpretation and appropriate action in response to a particular EFM pattern do not exist except in the face of tracings that are perfectly normal or extremely and obviously abnormal. This contention is primarily based on three studies.(8)

Reality: These studies are unpersuasive and outdated, with one being more than 23 years old and each involving no more than ﬁve obstetricians. For many years, highly-qualified obstetricians from all over the country have testified in medical malpractice cases that standards of care indeed do exist for the interpretation and management of various EFM tracing patterns that fall between those two extremes.

When EFM patterns provide evidence of impending fetal asphyxia, such patterns need not reach the extremely abnormal level before immediate action, such as expedited Caesarean delivery must be taken. Yet, because medically sanctioned literature suggests that less-than-extreme EFM tracings don’t necessarily require intervention, many otherwise healthy babies sustain intrapartum brain injuries and are subsequently diagnosed with CP. In connection with a medical malpractice lawsuit brought by a Minnesota mother whose child developed CP as a result of intrapartum asphyxia, a medical article was uncovered that shed light on at least one reason why doctors resist establishing written standards for the interpretation and management of the so-called in between patterns. “Providers have traditionally been hesitant to codify guidelines for managing FHR [fetal heart rate] pattern tracings. The reasons commonly cited include…fears that written guidelines will be used to scrutinize clinical practice in a court of law.”(9)

More Misguided Priorities

As much as parents would like to believe that the best interests of mother and baby are always the ﬁrst priority of the doctors and nurses who treat them, unfortunately, other considerations possibly come into play. According to the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN), nurses may hesitate to document a physician’s conduct in the medical record for fear those notes will end up in the courtroom: “[Nurses] are usually told by risk management personnel not to ‘advertise’ potential conflicts in the medical records and thus some nurses may be unwilling to memorialize an unsuccessful interaction with a physician…Nurses may choose to affirmatively protect the doctor by not documenting an inappropriate or untimely response in the patients chart.”(10)

Once parents like you learn that even a publication of a professional nursing organization notes that its members are cautioned against documenting potential medical errors, you will realize the gravity of this matter and the importance of researching these issues.

A Call To Action

Significant numbers of highly-qualified, respected physicians have concluded that many cases of cerebral palsy can be prevented through the judicious use of electronic fetal monitoring. Their positions are supported by recent medical studies that have established a distinct relationship between certain fetal heart rate patterns and poor neurological outcomes in infants up to a year after birth.(11)

And while there may be no universally agreed upon set of terms to describe actionable EFM pattern characteristics, it is clear that doctors know a great deal about the patterns that foreshadow CP and other poor neonatal outcomes. By using EFM in 85 percent of all labor and delivery rooms nationwide, the medical community already has acknowledged EFM’s value. Now, medical leaders should take action to adopt clear-cut written protocols concerning the interpretation of EFM tracings and appropriate interventions. Doing so will help reduce the number of errors made in connection with interpreting and responding to EFM tracings.

Healthcare organizations that promote better patient care should develop formalized classes and seminars that focus not only on easing the mother’s pain, but also on educating parents-to-be about EFM and other matters that will help them be proactive in their health care.

These are complex, technical subjects, and some may be difficult to research, but accurate information is available. There really are standards, even if they have not been reduced to writing or codified by the obstetrical community. You, as parents, must do the research necessary to learn more about EFM and its value in the labor and delivery rooms. Remember, knowledge is power.

As I travel across the country representing parents of children with CP, I’m often asked, “Is there anything I could have done?” Second-guessing themselves only adds to the agony for these parents. I tell them, “No, there’s nothing you could have done.” A mother and father who have given themselves and their unborn child over to the care of professionals should never be held accountable for what happens in a labor and delivery room.

But what they can do to help someone else avoid what happened to them-or to reduce the risk of the tragedy reoccurring in their family-is an entirely different matter. Learning a few basics of EFM is not difficult. It is imperative to recognize significant fetal heart rate decelerations (dips below the baseline rate) in the fetal monitor tracings. You must also understand the relationship of decelerations to contractions. Isolated decelerations of short duration (less than 30 seconds) generally are thought to be inconsequential. However, if certain types of decelerations become repetitive or prolonged, this could mean your baby is not being adequately oxygenated. You should also realize that the presence of variability (the second-to-second and longer-term jagged lines or variations in the fetal heart rate tracings) is usually reassuring. On the other hand, decreased or absent variability can be foreboding. Armed with sufficient knowledge, you will be able to question your healthcare providers intelligently. Some AWHONN publications provide easily understandable information about EFM patterns.(12) Well-founded questions will spark your healthcare providers to be more attentive to your care and that of your unborn baby.

Other important pro-active measures that parents should take include:

  • Help dispel the myth that CP rarely results from intrapartum asphyxia. It only hampers prevention efforts.
  • Be sure that your healthcare providers have the appropriate training, certifications, and experience necessary to properly interpret fetal monitor tracings.
  • Make sure your labor and delivery healthcare providers know you want to be informed about evidence of reduced fetal oxygenation and interventions that are being considered.
  • Conﬁrm that an obstetrician and anesthesiologist are in-house and available to respond in an emergency situation.
  • Understand the chain of command in the hospital so that if you feel your concerns are being ignored you have an alternative source for an opinion and intervention.

The moral for parents-to-be: Get proactive about your pregnancy and delivery. Move past the curriculum of Lamaze classes. Learn about more than how your baby is developing in the womb. Educate yourselves about EFM, and learn the right questions to ask about how your baby is being monitored during labor and delivery.

Because there really is only one certainty, and it is this: No one—no one—cares as much about your child as you do.

Howard A. Janet, is a principal in the law ﬁrm of Janet, Janet and Suggs, LLC which concentrates in the area of birth injury litigation. Giles H. Manley, M.D. (Board Certified Obstetrician), J.D., a partner with the ﬁrm, also contributed to this article.
(Copyright 2005 Cerebral Palsy Magazine, All Rights Reserved)

1. ACOG Practice Bulletin #62: Intrapartum Fetal Heart Rate Monitoring Obstet. Gynecol., May 2005; 105: 1161 – 1169.
2. Id.
3. Id.
4. Shevell, Michael I., M.D., CM, Majnemer, Annette, Ph.D., Morin, Isabelle, MSc, Etiologic Yield of Cerebral Palsy: A Contemporary Case Series, Pediatric Neurology Vol.28 No.5, 2003, 352-59.
5. Volpe, Joseph, J., M.D., Neurology of the Newborn, Fourth Edition, 2001.
6. ACOG supra note 1.
7. Paul, Richard H., M.D., Vincent v. Allina Health Systems, 2004.
8. Beaulieu M.D., Fabia, J., Leduc, B., et al., The Reproducibility of Intrapartum Cardiotocogram Assesment. Can. Med. Assoc. J. 1982, 127: 214-6.
9. Parer, Julian T., M.D., Ph.D., et al., Fetal Heart Rate Monitoring: Interpretation and Collaborative Management Journal of Midwifery & Women’s Health, Vol. 45, No. 6, November/December 2000.
10. Rostant, Donna Miller, Cady, Rebecca F., Liability Issues in Perinatal Nursing, Association of Women’s Health, Obstetric and Neonatal Nurses, 1999.
11. Volpe, supra note 5.
12. Feinstein, Nancy, R.N.C., M.S.N., McCartney, Patricia, R.N.C, PhD. Fetal Heart Monitoring Principles & Practices, Association of Women’s Health, Obstetric and Neonatal Nurses, Second Edition, 1997.
13. Beaulieu M.D., Fabia J., Leduc B., Brisson J., Bastide A., Blouin D., et al. The Reproducibility of Intrapartum Cardiotocogram Assessments., Can Med Assoc. J., 1982;127: 214-6

Was Your Child's CP Preventable?