My patient needed to be delivered. She had just developed eclampsia … She had suffered a seizure and dangerously high blood pressure …
… we gave medication to start labor, and the nurses placed a fetal heart monitor.
… 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.
… 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.
… bad fetal heart strips are an important cause of high cesarean section rates …
… 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 … the baby not getting enough oxygen during labor [which] 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 invasive surgery: cesarean section …
The odds of my patient’s baby suffering from dangerous lack of oxygen were slim … only 1 of 500 babies with a bad strip had cerebral palsy … it remained unclear if the condition had developed before labor, in which case cesarean couldn’t prevent it.
… fetal heart monitoring failed to reduce perinatal mortality … and increased cesarean section rates and forceps deliveries, compared with listening to a baby’s heart rate intermittently.
As a medical student, I loved watching emergency cesarean sections. The baby’s heart rate went down, doors swung open, residents rushed the patient down to the OR, and a frantic minute or two of surgery later, a screaming baby was out … I never questioned the need for the surgery.
Now, cesarean sections for bad tracings are one of the least satisfying parts of my job.
… “A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best,” … “Electronic fetal heart rate monitoring has probably done more harm than good.”
Why do doctors cling to continuous fetal heart monitoring? An obstetrician will most 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.
… I struggled with my patient’s bad fetal heart strip. I wanted her to avoid a cesarean section. She had type 1 diabetes, and I expected her sugars to swing wildly after surgery, and her recovery to be slow.
… Finally, at 3 a.m., I felt compelled to recommend cesarean … My patient’s child greeted the world pink and well-oxygenated.
The test was wrong again.