Topic Four B - Foetal Distress and Monitoring.My name is Debby Miller. I am a thirty something mother of two boys. One born by caesarean and the other a VBAC. I work full time as a financial adviser in a Government Department and am currently studying two degrees Accounting and Human Resource Development. From my work and study I have developed a good ability to research things. A skill that was particularly helpful to me when I was researching for my VBAC birth. I have a great interest in birth issues, particularly related to being an informed patient because of my first bad birth experience and my subsequent good one. I have offered to write a series of articles about a variety of subjects for Birthrites in the hope that my experiences and investigative abilities can help other mothers and mothers to be to make informed decisions about their birth choices. The topics I intend to write about are shown in the Discussion Topics Index. I will not be writing them in any specific order or to any specific time frame. I would advise all readers to read the first article Believing What You Are Told as this provides the basis for you to understand how assessments are made, both by myself and in the references I use, on the remainder of the topics discussed. I will try to keep the articles simple and will provide examples where possible. If medical terms are used I will add them to the Glossary so you can see what they mean. I would ask that readers note that I will try to keep the research factual and not input my own personal bias, however whilst I am aware of my own prejudices, I will probably lean towards documentation that supports my view. Secondly I am not a medical practitioner, nor do I have any medical training. The information I present will be based on research, journal articles and texts, and my interpretation of those. I will quote all references. Women wishing to use the information I provide are recommended to read the references for themselves and should discuss any issues pertaining to their own medical management with a qualified medical practitioner or midwife. Topic Four B - Foetal Distress and Monitoring NOTE: This particular topic is so large that I did it in two parts. The first part covered What Is Foetal Distress and Diagnosing Foetal Distress and can be found in the March edition of the Birthrites Magazine and on the website. In the second part we will cover How Accurate Are These Methods At Diagnosing Foetal Distress and Actions Taken When Foetal Distress Is Suspected. Introduction Where the parent is unsure of the diagnosis there is always the scope to ask for a second opinion. The risk of the time that it takes to do this needs to be understood and weighed up by the parents. For understanding risks see my first article 'Believing What You Are Told' on the Birthrites webpage. How Accurate Are These Methods At Diagnosing Foetal Distress
Given the lack of information on the question we wanted to answer, we will look at the evaluation of the methods of diagnosing distress. What this information will really mean is dubious. The reason it is dubious is because there is no one criteria against which it is being evaluated. The only evaluation criteria is the opinion of the writers of research as to what constitutes fetal distress, and as we have seen this varies significantly from one practitioner to another. Thus for research this means that if another person had done the research with exactly the same outcomes and group of participants they may come up with an entirely different conclusion because their opinion of what fetal distress is is different from the first researcher. In trying to evaluate what outcome the practitioners are trying to achieve with the use of monitoring, I could find only one direct reference as several allusions. Ref 1 discusses whether electronic fetal monitoring is worthwhile. In the statement of its value they state: "The Cochrane Collaboration concluded that, compared with intermittent auscultation, EFM does not reduce the rate of perinatal deaths, the rate of APGAR scores below 7 or the number of infants admitted to neonatal intensive care. " This would indicate that the purpose of monitoring is to avoid deaths, APGAR scores below 7 and infant admissions to intensive care. Other references also quote reduction in asphyxia injuries (without defining these) and cerebral palsy (which as we saw in part one is now not generally thought to be related to fetal distress and asphyxia). A Little History. In the 1960s and 1970s, continuous electronic fetal monitoring (EFM) was introduced with the idea that it would help clinicians diagnose fetal hypoxia in time to prevent perinatal neurologic damage. By the early 1990s, more than 75 percent of the nation's birth attendants had switched from intermittent auscultation to EFM. Ref 1 Electronic Fetal Monitoring Ð What is Best Continuous or Intermittent?
So does continuous monitoring really mean a better outcome for the baby where fetal distress is diagnosed? It would appear not. In Ref one it was identified that the continuous monitoring does not reduce the rate of prenatal deaths, the rate of APGAR scores below 7 or the number of infants admitted to neonatal intensive care, when compared with those who were only monitored intermittently. In addition continuous monitoring does pose and increase risk to the mother as it is associated with a higher incidence of cesarean section and operative delivery (vacuum extraction and forceps) and a higher risk of other interventions such as augmentation and epidurals. Ref 1, 2, 3, 4, 5, 6 and 15. Both the US and Canadian task forces have stated that: One of the problems with intermittent monitoring is that it is manpower
intensive. Ref 2 stated that: Therefore if your doctor or hospital policy states you are to have continuous monitoring you may be quite right in asking if this is being done for the benefit of you and your child or to solve a hospital staffing problem? What If My Doctor Says I am High Risk? In ref 4 a study was conducted that specifically looked at high-risk
pregnancies, however the group studied was small in number. In this
study they stated that: Again this study did indicate a significant increase in caesareans
and operative vaginal deliveries when electronic fetal monitoring
was used. They go on to say: Problems With Monitoring What About Other Forms Of Monitoring. The only device upon which I could find any studies was the Pinard Stethoscope. Ref 3 compared the use of electronic monitoring, doppler monitoring and the Pinard stethoscope. They found that the use of doppler monitoring was more reliable in detecting abnormalities in the fetal heart rate than the Pinard Stethoscope, and that overall the fetal outcomes were better among the doppler monitored group. How Can Suspected Foetal Distress Be Treated Conservative treatment is more about observation and benign actions. It is usually done under the premise that the fetal distress is temporary and minimal actions should see it resolve. Active Management. Prophylactic Tocolysis. This is the use of drugs called betamimetics (and other agents) that are used to relax the uterus and thus improve placental blood flow and therefore fetal oxygenation, in cases where fetal distress is suspected. They may be used either in preparation for caesarean or as a treatment in themselves. The study found that the treatment did appear to reduce the number of fetal heartrate abnormalities and uterine activity, but there was not enough evidence to show that it effectively helped fetal distress outcomes. The study did that the treatment showed an increased risk to the mothers cardiovascular system (heart and circulation. Ref 7. Piracetam. This is a drug that is thought to promote the metabolism of brain cells when they are hypoxic (oxygen deprived). It has been used to prevent adverse effects of fetal distress. The study found that when compared with a placebo (fake) it was found there was a trend in reduced need for caesarean section however the differences on fetal morbidity (measured by neonatal respiratory distress) or Apgar score were not significant. The Cochrane review concluded that their was insufficient evidence to make an assessment and more studies were required on the use of this drug. Auditory Evoked Response. It was found that babyÕs elicit a response to auditory (sound) stimulation and that their response diminished when they were in distress. This method will not cure fetal distress but may be an additional confirmation of whether distress actually exists or not. Ref 11. Associated Testing. A test that is sometimes offered when fetal distress is suspected is the fetal blood scalp test. This test identifies if there are indicators in the babyÕs blood that show oxygen deprivation. (You should check if this test is offered in your hospital as many smaller hospitals do not do it). Ref 2 indicated that instrumental delivery and caesarean section were even more common when continuous electronic monitoring was not backed up by a fetal blood sample. Consequently there was a significant increase in operative delivery, with its impact on the mother , without any gain for the baby. Ref 2 Conservative Management. Another known cause of fetal distress is maternal positioning. If the mother is lying on her back there is a strong likelihood that she is compressing the aorta, the lower bodyÕs main blood supply. If this is reduced then the blood available to the baby is also reduced thus potentially causing fetal distress. Common positions to alleviate this are lying on the left hand side and getting the mother up to walk around. Ref 14. Certain positions the mother assumes may also cause temporary cord compression in the baby. Merely changing the motherÕs position can alleviate this problem. Oxygen Treatment. Another action commonly taken is to give the mother oxygen. The study in Ref 13 found that there was some association between improved oxygenation of the fetus when oxygen was given for periods in excess of 10 minutes. However the group size examined wassmall and the reviewer indicates the results do not support the provision of oxygen prophylactically (just in case). Ref 13. Does Operative Management Have Better Outcomes For the Baby Than
Conservative Management. When such arguments are used to justify a cesarean section they should be considered in relation to what has actually been found to be the truth. In ref 1 it is indicated that outcomes are the same regardless of whether fetal distress is managed operatively or conservatively. Ref 9 states: "There have been no contemporary trials of operative versus conservative management of suspected fetal distress. In settings without modern obstetric facilities, a policy of operative delivery in the event of meconium-stained liquor or fetal heart rate changes has not been shown to reduce prenatal mortality." Ref 9. What About That Monitoring They Normally Do On Admission?
What If I DonÕt Want To Be Monitored At All? So What Should I Do? References:
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