The Inexplicable Persistence of EFM – Is the Law to Blame?
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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.
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- 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
- 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.”