Archive for November 2012

The “but it’s my baby” bias: when the evidence contradicts conventional wisdom practices in healthcare   Leave a comment

Editor’s Note: A change in the publication schedule has been made for the month of November. This post below replaces a previous November post on pharmaceutical markets in developing countries that will be re-published in the future.

Disclaimer: Every pregnancy is unique. The below discussion focuses on population-wide assessments of effectiveness and should not be used to make a decision about one’s personal healthcare. Any questions about the issues raised below with regard to the reader’s own pregnancy should be discussed with their obstetrician.

When a pregnant woman arrives to a hospital in labor, she will typically be whisked away to a Labor and Delivery ward. For those familiar with birth, the timing of what follows is highly unpredictable. If in true labor, she will be whisked to the room where she will deliver, and be allowed to progress for the often hours-long wait prior to delivery. After being immediately assessed, most institutions include protocols that have the ward nurses place a continuous fetal heart rate and uterine contraction monitor. The information gathered by the probes is then usually electronically transmitted to a central server for display on any number of desktop monitors and overhead displays scattered throughout the ward. The principal behind this monitoring is for the medical team to be able to readily assess the basic vital signs of labor on any patient from any location in the ward. For example, fetal heart rate decelerations are one recognized sign of fetal distress, and many institutions train staff to immediately respond to such a feature observed on monitoring. A frequent result of “ominous” or “nonreassuring” fetal heart rate patterns is that further observation of the fetal heart rate does not improve the assessment of fetal health and an emergent Caesarean section ensues.

As comforting as continuous fetal monitoring may appear, the devices’ tendency to prematurely warn of fetal distress may actually worsen outcomes for mother and baby. (Photo Courtesy: Medgadget)

Conventional wisdom would suggest that the current widespread distribution of such telemetry monitoring for active labor has saved the lives of countless women and their progeny. Until the twentieth century, pregnancy was one of the most dangerous periods of a woman’s life, and much of this was the result of difficulties during active labor without the ability to safely remove the near-term pregnancy. Even today, Caesarean section – with only minor technical modifications in the ensuing period – remains the standard of care for achieving optimal outcomes when persistent fetal distress is detected during active labor. Logically, one would then think that real-time vitals of the fetus would be the ideal technological assistance¬† for fetal health surveillance during this period of pregnancy.

Although such reasoning appears sound and is routinely used by purveyors of continuous heart rate monitoring, the scientific evidence to date does not support the use of such devices. Although proponents of continuous fetal monitoring have cited a large recent study that suggests otherwise, the best scientific evidence suggests that continuous fetal heart rate monitoring results in the same mortality outcomes for mother and fetus as what can be achieved with the traditional form of fetal health monitoring, or “intermittent auscultation” (a nurse rounding on the mother every 15 minutes and listening for the fetal heart rate with a stethoscope-like device). Worse, not only are mortality outcomes unchanged by an expensive piece of hospital IT infrastructure, but the studies have also shown that the number of Caesarean sections increases with the use of continuous fetal heart rate monitoring. What this constellation of findings suggests is that such monitoring does not improve health outcomes but also has the unfortunate disadvantage of “sounding the alarm” too early. In other words, continuous monitoring appears to be picking up fetal distress that is transient that may be more accurately described as “fetal discomfort.” These findings suggest that if such cases were left alone, the distress would often resolve on its own without any lasting effect on health outcomes for mother or baby.

To summarize, the amassed evidence to date suggests that continuous fetal monitoring does not improve newborn mortality and increases the number of C-sections performed when it is used. Why then is it the standard of care across much of the U.S.? I’ve put exactly this question to a number of my mentors and colleagues, and the answer is invariably the same. Evidence aside, no jury in the United States is going to be kind to the obstetrician who goes against the tide of medical practice to adhere to what “stuffy” academics suggest is a more effective treatment strategy. That a minority of institutions in the U.S. even still allow practitioners to use intermittent auscultation is testament to the American College of Obstetrics and Gynecology’s measured acceptance of both forms of fetal monitoring.

What troubles me the most about the state of fetal monitoring today is the potentially massive quality transformation that exists and the limited work being done to explore this issue further. Labor is one of the most common conditions requiring hospitalization and the question of how it is monitored affects every single one of those admissions. Definitive research is needed to settle this debate. Because such research may very well prove the futility of a profitable medical technology, it is likely that professional advocacy is the only way such work will get the necessary funding to conduct a large randomized trial. Without it, we will continue to perform a practice that is contributing to what may be thousands of unnecessary surgeries a year and a considerable cost burden to our healthcare system.

Disclosure: I have no financial or professional interests related to continuous fetal heart rate monitoring or other matters discussed above.

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