This document discusses the persistence of electronic fetal monitoring (EFM) despite evidence that it does not improve neonatal outcomes for low-risk pregnancies compared to intermittent auscultation. While EFM was introduced to screen for fetal distress and reduce cerebral palsy rates, multiple studies have found it does not achieve these goals. However, EFM continues to be used in 85% of deliveries and has led to increased cesarean rates and costs without clear benefits. The document examines possible explanations for EFM's persistence, including the influence of law and economics, and calls for more randomized trials before new medical technologies are widely adopted.

1. The Inexplicable Persistence
of EFM – Is the Law to Blame?
Julie D. Cantor, MD, JD
UCLA School of Law

2. Overview
• A Word on Systems
• The Story of EFM
• The Status Quo
• Explanations - Is the Law to Blame?
• Your Thoughts
• Closing Thoughts

5. What is EFM?

7. What is intermittent auscultation?

9. The Story of EFM

10. EFM: Solve Two Problems
1. Screening test for severe asphyxia
2. Allow for recognition of early asphyxia

11. On CP: Flawed Hypothesis
“Many lay people, and clinicians too, have come to
believe that birth abnormalities explain a variety of
neurologic and cognitive disorders in children.
In fact, there is little evidence to support this belief.”
- Paneth, NEJM 1986

13. On CP: Flawed Hypothesis
“The majority of cases of CP appear to be caused by
developmental defects, migrational defects, infections, toxins,
antepartum ischemic or asphyxial episodes in the fetus, and
other causes. Unfortunately, the prevalence of CP has not
decreased since the advent of FHR monitoring. . . . The hope that
FHR monitoring will abolish CP has proved to be an
unmeasurable and unrealistic goal.”
- Parer, AJOG 2000

14. Additional Concerns
• As a screening test (fetal death/CP), 99.8% false + rate
• Interpretation of the data is:
• subjective, difficult to standardize, poorly reproducible
• inter- and intra-observer variation
• Mobility, comfort measures
• Focus on machine, not patient
• Belief: Can prevent all perinatal mortality & neuro injury
• Abnormal pattern may reflect pre-existing condition

15. On EFM:
• Pseudodisease
• To prevent, intervene
• Dramatic increases in
• Rates of section
• M&M
• Cost of care
• Law suits
• Insurance costs
• No effect on incidence of CP

16. Rising Cesarean Rate

18. Status Quo

19. Prevalence of Use
• 85% of deliveries using continuous EFM
• #1 OB procedure
• 3.4 million US women at low risk screened annually

20. Structured IA is equivalent to continuous EFM in
screening for fetal compromise in low-risk patients.
An admission tracing of electronic FHR in low-risk
pregnancy increases intervention without improved neonatal
outcomes . . . routine admission tracings should not be
used to determine monitoring technique.
“the method of choice for the
monitoring of the fetus during normal
labour is intermittent auscultation”

21. “IA is the preferred method for monitoring the FHR
during labor for women at term who at the onset of
labor are low risk for developing fetal acidemia.”
“Given that the available data do not show a clear
benefit for the use of electronic fetal monitoring
over intermittent auscultation, either option is
acceptable in a patient without complications.”

22. “ineffective, but
nonetheless persistent”
- Michael Greene, MD
Mass. General Hospital

24. “Routine intrapartum EFM is not recommended for
low risk women. There is insufficient evidence
regarding its routine use in high risk pregnancies.”
“[T]he USPSTF believes that updating its 1996 recommendation
would have limited potential impact on clinical practice.
The USPSTF will not update its 1996 recommendation.”

25. Explanations
(Is the law to blame?)

26. Explanations
• No problem
• Psychology
• Economics
• Education
• Law

27. Your Thoughts

28. “The story of electronic fetal monitoring also
illustrates the need for proper randomized
clinical trials before new forms of technology are
introduced that may become the standard of
practice without clearly demonstrated benefit.”