My Patient Needed to Be Delivered

My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.

So we gave medication to start labor, and the nurses placed a fetal heart monitor.

Worn like a belt, but higher on the abdomen, the ultrasound monitor would play a crucial role in the hours to come. It prints a read-out strip of the baby’s heart rate, and the pattern would guide us in determining whether the delivery would be natural or through cesarean section.

As I suspected, the baby’s heart-rate strip showed worrisome changes soon after labor began, and I knew it would get worse as labor progressed. We would fight through the night to have a natural delivery. But ultimately that single heart-rate test, which is surprisingly unreliable, would be a key factor in whether my patient would get a C-section or not.

Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates. A recent report detailed the dizzying increases: Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available. That rate has grown by more than 50 percent in a decade.

I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips.

A jagged pattern indicating increases in the heart rate reassures us that the baby’s brain is awake and alert, and that labor could continue. But a flat line or decreases in the heart rate after contractions make us think the baby is not getting enough oxygen and pushes us to do a C-section – delivering the baby through incisions in the abdominal wall and the uterus.

For the worst readings, we believed every second counted and rushed the surgery: If the baby wasn’t delivered one minute from the first incision into the skin, we had moved too slowly.

The complication we feared most was hypoxia, the baby not getting enough oxygen during labor. Going too long without adequate oxygen could result in a serious permanent injury, such as cerebral palsy, or even death.

No test is perfect. But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry.

Were we saving lives and averting disaster? Or were we performing unnecessary surgery?

Fetal heart-rate monitoring is a screening test. Good tests get several things right; they are cheap, detect a possible problem when there is still time to act, and minimize unnecessary follow-up tests.

Fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and expensive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.

Why do doctors cling to continuous fetal heart monitoring? An obstetrician will likely point to the fear of being sued, but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don’t work and can cause harm. “It’s our bias that anything that can be quantified is an improvement,” said H. Gilbert Welch, a professor at Dartmouth Medical School whose research focuses on harm caused by screening and over-diagnosis.

“I think we get in trouble when we start promising things to . . . well [patients],” Welch said in an interview. “It is not that hard to make them worse.”

Throughout the night, I struggled with my patient’s bad fetal heart strip. I wanted her to avoid a cesarean section. To improve the strip, the nurses and I tried giving her oxygen, changing her position in the bed, even rubbing the baby’s head through the cervix to wake it up.

Finally, at 3 a.m., I felt compelled to recommend cesarean. The strip continued to look bad, and my patient’s labor progressed slowly.

We went to the operating room, and delivered the baby by cesarean. My patient’s child greeted the world pink and well-oxygenated.

The test was wrong again.

Alexander Friedman, MD, a fellow in maternal-fetal medicine at the University of Pennsylvania.

Costs of Care (Twitter: @CostsOfCare), where this post was originally published, is a Boston-based nonprofit organization that collects anecdotes from doctors and patients. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, and also because they unveil how commonplace and pervasive these types of stories happen.

12 replies »

  1. Great post,very enjoyable read,and I agree with most of what you say,and by the way,here is a great info about how to become a game tester

  2. Ummm….I’ll take a false positive, and a pink screaming infant, over wait and see and blue and limp. Babies are good until they are bad.

    Ask any birthloss mama. They would give their right arm to have had a section and a live infant…..

  3. fhm is not a good test for monitoring eclampsia. nor is the outcome of a pink, crying baby an effective measure of mom’s cerebral O2 mismatch, or the dozen other significant metabolic perturbations of eclampsia.

    pretty poor case example for discussing the merits/shortcomings of fhm. eclampsia, while dramatic, clouds the issue. fhm tracings are notoriously difficult to interpret while mom is seizing.

  4. The above make it sound as if some enlightened OB doc should bravely step forward and be the first to abandon continuous FHR monitoring. You all have to know that such a doctor would be crucified after the first bad outcome. The author tries to say that fear of litigation is only partially responsible, and yet the author is unwilling to abandon this “appallingly poor test.” I find it hard to believe that the reason for that is because he likes data.
    Yes it would be nice for “the industry” to come up with a comfortable and accurate device, but that would risk the unpleasant possibility that a doctor might benefit financially from their association with the device manufacturer. Also, don’t forget that in the case presented it was not the fact that the heart rate was not being monitored accurately, it was that the data, even though accurate, could not lead to an accurate assessment. Is FHR monitoring better or worse than no monitoring at all? That unfortunately is a legal question, not a medical one. Unless maybe you could do a study in say, India, where “ethics” would not interfere with the barbaric idea of letting a few hundred American women proceed through labor without the FHR monitor.

  5. I’m not a doctor, (I did have a bunch of kids though), but if you can try “rubbing the baby’s head through the cervix to wake it up”, why can’t you attach the electrodes to the scalp?

  6. My wife had continuous monitoring from the time we got to the hospital (because she was already ready to push & fully dilated). The monitor was big, clumpy, kept on falling off, was very very uncomfortable–verging on painful–and it continuously gave readings that just weren’t possible 90 one second 150 3 seconds later, 70 5 seconds later then back to 120. It was looked at like gospel by the OB and the nurse although it was clear that it was moving around on her body and losing the heartbeat. Then the OB started talking about fetal distress and being worried about the heartbeat. My wife moved onto her back (more comfortable for the OB at least!) and apparently the concern went away–even though the readings were still intermittently all over the place. And of course the baby was normal, pink & healthy.

    If that form of minor torture is necessary the least the industry could do is come up with a comfortable and accurate device. Until then they probably should be abandoned and replaced by occasional portable ultrasound monitoring.

  7. Well-stated. Important. No test is perfect, all have risks, many underperform, are over-relied upon or not well understood. Yet in this environment of uncertainty we have to make complex devisions with potentially huge consequences. What a challenge! Thank you.

  8. As clearly stated in the first paragraph the woman had a seizure which is the diagnostic criteria for eclampsia verus preeclampsia. Eclampsia may still be able to be managed medically and allow the woman to have an induction/vaginal birth.

    As for using the scalp electrodes, the woman has to be at a
    point in her labor which would allow for that, namely having cervical dilation great enough to pass the electrode though the cervix and onto the baby’s scalp.

    The point of the article? Namely as you also pointed out that the belt ultrasound is way to inaccurate for its continued use as an assessement to make such important medical decisions.

  9. Don’t you use scalp electrodes anymore? A belt ultrasound is not very accurate sometimes.

    Also it sounds like you must mean “pre-ecclampsia”. Her care was rather leisurely for “ecclampsia”.

    It is not a matter of the test being “wrong”.

    It was the doctor who was not “wrong”.

    What was your point?