I was just reading about a new invention that the media are calling ‘the pregnancy patch’ (although it seems it is meant to be used during labour to measure contractions and fetal heart rate) will apparently lower intervention rates.
I am left wondering how a new obstetric technology is going to lower intervention when all the others have been shown to increase intervention.
(This is referred to as the cascade of interventions that is actually “normal” birth now, but that is another blog).
Admittedly, I have only read the SMH article and not the research but there is no explanation of how this new system of continuous electronic monitoring is going to improve outcomes and lower interventions when the current method of continuous electronic monitoring hasn’t.
I understand that the intention for this new device is for it to be used in high risk situations.
But I fear, like so many other obstetric interventions that were only meant for high risk situations, it will soon be used on low risk women too.
Not unlike the obstetrician him/herself.
I really think we need to be looking at whether we need the technology in the first place rather than looking for ways of making it more palatable to women.
Here is what the 2017 Cochrane Review into continually electronic monitoring (CTG) concluded:
“CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.
The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).
Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women’s and clinicians’ choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women’s mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.“
This Review raises a few inconvenient truths.
Inconvenient Truth No 1.
CTGs do not improve neonatal outcomes but they do increase caesarean section rates.
They do seem to lower neonatal seizures possibly because they are picking up signs of hypoxia cause by women lying on their backs because they are strapped to monitors (face palm).
Which is possibly the benefit of the new invention, but this leads us to inconvenient truth no.2.
Inconvenient Truth No. 2
If women use “mobility and position” in birth they can reduce the risk of hypoxia and wouldn’t need monitoring.
It has long been established that lying on your back (supine) during labour and birth causes “decrease in fetal cerebral oxygenation”.
Surely it would be better to prevent fetal hypoxia (and the associated fetal heart rate decelerations) by not insisting women birth on their backs rather than connecting women to a device to pick up the fetal heart rate decelerations once we have caused them?
Whenever I hear that a woman has had a c-section because her baby was distressed I always ask what position she was labouring and birthing in?
Inconvenient Truth No. 3
Technology is no replacement for clinical skill, yet overuse of technology is reducing clinical skill levels.
I have been worried about this for a while now.
Our overreliance on technology in obstetrics means that midwives and obstetricians are losing the important skills of clinical observation and decision making.
To be fair to the technocrats, they are starting to acknowledge this and have come up with a solution …use computer software to do it!
So does using more technology rather than improving clinical skills work?
The INFANT research showed that using a “decision-support system” did not improve clinical outcomes for mothers or babies because it didn’t use other important clinical information and observations.
We need to stop inventing more technology and focus on training obstetricians and midwives in the disappearing skill of clinical observation.
Inconvenient Truth No. 4.
We know what improves outcomes but not only are we not giving women access to it, we are not even telling them about it.
It is not continuous electronic monitoring that improves outcomes, it is continuous support for women during labour.
Another 2017 Cochrane Review found that:
“Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support. Subgroup analyses should be interpreted with caution, and considered as exploratory and hypothesis-generating, but evidence suggests continuous support with certain provider characteristics, in settings where epidural analgesia was not routinely available, in settings where women were not permitted to have companions of their choosing in labour, and in middle-income country settings, may have a favourable impact on outcomes such as caesarean birth. Future research on continuous support during labour could focus on longer-term outcomes (breastfeeding, mother-infant interactions, postpartum depression, self-esteem, difficulty mothering) and include more woman-centred outcomes in low-income settings.”
I know that in a culture where a “healthy baby” is all that matters, the outcomes of:
increased spontaneous vaginal birth,
shorter duration of labour,
decreased caesarean birth,
decreased instrumental vaginal birth,
decreased use of any analgesia,
decreased use of regional analgesia,
improved five-minute Apgar score
and decreased negative feelings about childbirth experiences, may not be news worthy.
But what about the outcomes of fewer preterm births, fewer stillbirths and fewer neonatal deaths?
These are the improved outcomes that happen when women have access to a Midwifery-led Continuity of Care as shown by this 2016 Cochrane Review:
“Women were less likely to experience preterm birth, and they were also at a lower risk of losing their babies.”
The 2017 WHO statement for “The Case Of Midwifery” declared that:
“83% of all maternal deaths, stillbirths and newborn deaths could be averted with the full package of midwifery care (including family planning)”
Why isn’t this headline news?
Possibly because the media seem to think that the AMA is THE voice for public health.
They seem to forget that the AMA is a union whose first and foremost agenda is to promote and protect the professional interests of doctors.
And with the current national head of the AMA being an obstetrician it is no wonder that they are not letting the public know that Continuity of Care by a known midwife leads to more healthy babies and healthy mums.