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Perpetuating Myths, Fables, and Fairy Tales:
A Half Century of Electronic Fetal Monitoring
Thomas P. Sartwelle1James C. Johnston2Berna Arda3
1Beirne, Maynard and Parsons, LLP, Houston, Texas, United States
2Legal Medicine Consultants, Seattle, Washington, United States
3Department of Medical Ethics, University of Ankara, Ankara, Turkey
Surg J
Address for correspondence James C. Johnston, MD, JD, Legal
Medicine Consultants, 321 High School Road, Suite D3-750, Seattle,
WA 98110, United States (e-mail: johnston@GlobalNeurology.com).
Doctors are men who prescribe medicines of which they
know little, for dise ases about which they un derstand even
less, for people about whom they know nothing.
—Voltaire
Every time a mother is hooked up to an electronic fetal
monitor (EFM), she subjects herself and her baby to potential
but undisclosed harm, including death, injury, disability, and
the very real possibility of chronic lifelong disease. These
potential consequences have been known to medicine since
the inception of EFM, yet remain undisclosed to millions of
mothers. Rather, EFM has been sold to patients as a necessary
safety device.
It has become popular for physicians today to concede that
EFM has been without evidence of clinical efficiency for the
nearly half century of its use in monitoring the vast majority
of pregnant women in the industrialized world.1–6Conceding
EFM’s uselessness, and even acknowledging EFM’s potential
to cause some harm—primarily by compelling unnecessary
cesarean sections—it has been equally popular for EFM
proponents to argue for continued clinical use of the modali-
ty. These arguments are consistently affirmed by birth-relat-
ed professional organizations (BRPOs) worldwide.1–6
These are prodigiously astounding arguments. Not only do
EFM proponents ignore the vast hoards of empirical evidence
of EFM-induced harm to mother and babies, but they ignore
logic and reason as well. Even more importantly, EFM pro-
ponents also purposely flout the bedrock bioethical princi-
ples of autonomy, beneficence, and nonmaleficence by
advocating continued EFM use, in particular EFM use without
mothers’informed consent. And despite the arguments for
continued EFM use being totally devoid of ethics, there has
been no protest from organized medicine, BRPOs, clinicians,
or ethicists. EFM has received an ethics pass.
Why has the me dical world remained virtually s ilent while
a machine known to be junk science has been presented to
laboring mothers for nearly a half century cleverly disguised
as a device necessary for safe delivery that can predict the
baby’s future? Because the reason EFM is used in virtually
every labor is as a defense by physicians, nurses, and hospitals
Keywords
►cerebral palsy
►electronic fetal
monitoring
►medical ethics
►medical education
►medical malpractice
Abstract Electronic fetal monitoring (EFM) entered clinical medical practice at the same time
bioethics became reality. Bioethics changed the medical ethics landscape by replacing
the traditional Hippocratic benign paternalism with patient autonomy, informed
consent, beneficence, and nonmaleficence. But EFM use represents the polar opposite
of bioethics’revered principles—it has been documented for half a century to be
completely ineffectual, used without informed consent, and harmful to mothers and
newborns alike. Despite EFM’s ethical misuse, there has been no outcry from the
bioethical world. Why? This article answers that question, discussing EFM’s history and
the reasons it was issued an ethics pass. And it explores the reason that even today
mothers are still treated with blatant medical paternalism, deprived of autonomy and
informed consent, and subjected to real medical risks under the guise that EFM is an
essential safety device when in fact it is used almost solely to protect physicians and
hospitals from cerebral palsy lawsuits.
received
September 10, 2015
accepted after revision
October 9, 2015
DOI http://dx.doi.org/
10.1055/s-0035-1567880.
ISSN 2378-5128.
Copyright © by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
THIEME
Perspective
against cerebral palsy (CP) lawsuits, another long-standing
birth myth. But the use of a scientifically bankrupt machine
solely to benefit physicians when it harms patients is simply
an egregious endorsement of obstetric defensive medicine—
postmodern ethical relativism solely for the benefit of physi-
cians—and is undeniable proof that bioethical principles are
nothing more than empty rhetoric.
A Medical Myth Is Born
In the 1950s and 1960s, amid the nascent technology revolu-
tion, space race, and medicine’s conquest of diseases that had
tormented the world for generations, several researchers
were independently inventing a computer-like fetal heart-
beat counter.5,7–9The invention was motivated by the per-
ceived need to replace humans at the heartbeat-counting task
of intermittent auscultation during labor.5,7–9Counting fetal
heartbeats emanated from an 18th-century unproven theory
that asphyxia during labor caused CP and other neurologic
birth maladies. That theory merged into the theory that an
abnormal fetal heart rate was a direct, accurate measure of
past and present fetal brain damage.5,7 The theory soon
became dogma. Quick delivery was the cure from the asphyx-
ia causing CP or any other neurologic birth injury. At first,
interventions were with forceps and obstetric maneuvers, but
that quickly gave way to cesarean sections as surgical techni-
ques and anesthesia improved.5,7,8 The EFM inventors, rather
than questioning the theories that had been accepted by
generations of physicians before them that CP’scausewas
asphyxia and that abnormal fetal heart rates accurately
reflected brain damage, concentrated on counting heartbeats.
It is unfortunate that the inventors overlooked proving the
dogma, because it is nothing more than myth, fable, and fairy
tale.6,8–24
Cerebral Palsy’s Nemesis
The EFM inventors did not rely on clinical trials. EFM efficacy
was proven by uncontrolled clinical assessments and anec-
dotes.5,7,8,16,20,23,24 Nevertheless, the clinical obstetric com-
munity received EFM with enthusiasm, because fetal
monitoring did not involve new concepts. EFM merely auto-
mated the critical task of heartbeat counting that previously
had been done manually.24 EFM inventors were even more
enthusiastic. They predicted that EFM alone would reduce by
half intrapartum deaths, mental retardation, and CP.25
A New Medical Phenomenon: Defensive
Obstetrics
In 1970, as EFM began revolutionizing clinical obstetrics, two
other seemingly unconnected simultaneous revolutions
gained momentum. One was the revolution in legal liability
theories and evidence law, which was exponentially expand-
ing medical malpractice lawsuits, causing the first of many
malpractice insurance crises.6,9,11,26 The second was a slower
sea change collapsing the Hippocratic tradition—the physi-
cian chooses what is best for the patient—to bioethics, a code
based on secular liberal political philosophy—the physician
provides the patient with treatment option information,
thereby enabling the patient to make medical decisions
autonomously.27–29 No one knew that these revolutions
would merge to create a maelstrom that put trial lawyers,
not physicians, in charge of labor room decisions and created
a phenomenon previously unknown in medical history—
defensive medicine: treatments disguised as medical care
that are solely for the physicians’protection from trial
lawyers.6,9–11
The Perfect Storm
Before EFM, there was little in the way of obstetric medical
malpractice. Intermittent auscultation resulted in recording
what the physician heard, and no amount of cross-examina-
tion could change a doctor’s recollection that the fetal heart
tones were normal during labor. EFM changed everything.
EFM provided a permanent second-by-second computer-like
graph of the entire labor, a graph that years or even decades
after birth could be critically analyzed by EFM “experts”who
specialized in courtroom obstetrics. These experts could,
without fail, deliver neurologically perfect babies every
time by performing the just-in-time cesarean section that
saved the infant from certain devastation. Defendant physi-
cians, on the other hand, not as capable, well-educated, or
attentive as the courtroom experts, sentenced a child to the
lifelong neurologic devastation of CP, cognitive diminution,
seizures, and other conditions, all because of his or her
negligent EFM mismanagement and failure to perform a
“simple”cesarean section. Lawsuits multiplied exponentially,
as did the amount of the CP verdicts and settlements, many so
enormous they rivaled business litigation lawsuits.6,9–14,19,21
Forty years of the EFM–CP punitive litigation cottage
industry have enriched trial lawyers and their experts, but
rarely the children with CP10,12,13,15,19,21; made physicians
and hospitals into a social welfare insurance scheme; driven
caregivers away from obstetrics; closed obstetric services to
the public; and for more than a generation diverted research
away from CP’s true causes.6,10–13,15,19,21
How? Because physicians, convinced that the birth dogma
accepted for multiple generations was the cause of CP, sought
to protect themselves by concentrating solely on a system
whose inventors promised would defeat CP and most other
birth defects—EFM. Ironically, the choice to make EFM the
deus ex machina led inevitably to more and bigger CP verdicts
and settlements, multiplying the anxiety level associated
with each birth and causing physicians to abandon true
patient care in favor of protecting themselves from harm,
rather than protecting their patients.20
Willful Ignorance
In 2013, thought leaders in the maternal–fetal medicine
community conceded that five decades of EFM research,
investigation, and clinical use had failed to reduce the inci-
dence of CP or any other neurologic malady.30 EFM had
resulted in an exponentially increased cesarean section
The Surgery Journal
Perpetuating Myths, Fables, and Fairy Tales Sartwelle et al.
rate, driven primarily by CP-related litigation as well as the
realization there was a consistent absence of scientific evi-
dence that interventions in labor based on any single or
combination EFM patterns did not prevent CP or other
neurologic impairment.30 These scholars conceded that it
was time to start over, because, despite a half century of
meetings, conferences, and task forces designed to make EFM
viable, EFM still lacked common language, standard inter-
pretations, and reasonable management principles and
guidelines.
All of the EFM faults outlined by these scholars had been
known for decades, but had remained secrets within the
medical community, never shared with the millions of moth-
ers undergoing EFM assessments. In fact, the secret EFM
faults, flaws, imperfections, and weaknesses were even
more sweeping than the maternal–fetal medicine scholars
admitted—so sweeping that EFM should have been discarded
on the junk science trash heap after the first real clinical trial
in 1976 found no EFM benefit but significantly increased
cesarean sections.6,9 BRPOs’willful blindness and the desire
to protect doctors and hospitals from lawsuit are the reason
EFM survived. Nevertheless, there was a price to be paid. And
it was mothers and babies who paid the price.
Faults, Flaws, and Foibles
Clinical trials organized years after EFM use had already
become popular showed no EFM benefit compared with
intermittent auscultation. Between 1976, when the first trial
was reported, until 1995, 12 clinical trials found no EFM
benefit but a substantially higher cesarean section
rate.6,9,11,31 Along the way, a few obser vers plainly told BRPOs
and the medical community that CP was not caused by
asphyxia,32 that EFM was a failure and a waste of
time,8,17,18,20,21,23 and that using EFM to deliver babies by
cesarean section in response to EFM patterns was causing
more harm than good,14,17,19,22 and some suggested early in
the process that EFM should be abandoned.24
But BRPOs and their members ignored that evidence and
the evidence that EFM pattern interpretation, even among
experts, was contradictory, highly unreliable, and difficult to
teach.9,11,31 And despite four decades of effort to improve
EFM pattern interpretation, it remained subjective, impossi-
ble to standardize, poorly reproducible, with inter- and intra-
observer contradictions even more problematic today than in
the past.20,33–35
Protecting Doctors from Lawsuits: The
Undisclosed Price
EFM has consistently produced significantly more cesarean
sections than any other method of fetal surveillance. In
1970, the cesarean section rate was 2%.31 In 2013, 33%.36
Much of that increase was driven by defensive obstetrics—
cesarean sections in any case with a questionable EFM
pattern.6,9–14,17,19,21–24 Far better to do a cesarean section
than be sued for acting slowly. But the plain truth is that
80% of the EFM patterns are category II, for which BRPOs
have no clinical management guidelines or recommenda-
tions.30,37–39 Clinicians are on their own, with only a good
luck wish from their professional societies—the organiza-
tions that should be advancing evidence-based medicine
and helping their members avoid specious litigation.39 But
instead BRPOs’50 years of silence have done everything to
assist the plaintiff lawyers waiting on the sidelines for the
next physician or nurse perplexed by a machine that
confuses everyone in obstetrics, save and except the usual
courtroom experts, who never have difficulty interpreting
any EFM pattern and know precisely what to do and when
to act.19,21,40
The act favored by courtroom experts is the cesarean
section. Multiple times per year in courtrooms around the
world and on thousands of trial lawyer Web sites, courtroom
experts save babies from CP with a “simple, quick, safe
cesarean section”that never has complications or consequen-
ces. The defendant physician, if only he had done the same
thing, could have saved the child in the courtroom, wheel-
chair-bound, blind, deaf, or both, cognitively impaired, and
fed through a stomach tube. This testimony appeals to
laypeople, jurors, judges, and even many physicians, because
they do not perceive the serious risks associated with this
major abdominal surgery.41 The lay view of cesarean section
risks is perhaps best illustrated by the increase of the con-
cierge-like desire for cesarean sections on demand.42 And
although the attitude that a cesarean section is simple and
safe accounts for some of the dramatic cesarean section
increase, the primary driver of unnecessary cesarean sec tions
and, therefore, unnecessary risks for mothers and children, is
EFM’s unbelievable 99% false-positive rate and physicians’
litigation fears.6,9–15,19,21,39,41
But for almost half a century practitioners and their BRPOs
have ignored EFM’sflaws and the fact that nonemergency
cesarean sections have double the risk of complications com-
pared with vaginal birth43 (bleeding, infection, embolisms,
anesthesia reactions, surgical injuries41,44) and risks in subse-
quent pregnancies—repeat cesarean sections for life, uterine
rupture, operative complications from previous surgery, and
placenta previa and accreta.41,44,45 Could it be mere coinci-
dence that placenta accrete quadrupled over the past 40 years
(1 in 2,000 in 1980 to the current 1 in 500 pregnancies, making
placenta accreta the most common reason for cesarean hys-
terectomies in industrialized countries) or is it the cause and
effect of mounting lawsuit fears and ethical compromise
growing out of unneeded EFM cesarean sections?45
But known cesarean section risks may not be all that
physicians and hospitals have to fear. A growing body of
substantial evidence suggests babies delivered by cesarean
section are exposed to risks of future chronic diseases and
neuropsychiatric disorders.46–49 This risk may be the future
price to be paid for willfully ignoring EFM and its contribu-
tions to false-positive cesarean sections—an avalanche of
suits claiming a child’s chronic disease was induced by false
EFM signals causing the physician to perform an unnecessary
cesarean section.
A half century of research in CP and EFM has exposed the
myths, fables, and fairy tales forming the foundation for a
The Surgery Journal
Perpetuating Myths, Fables, and Fairy Tales Sartwelle et al.
continuing deceit foist upon mothers and babies by physi-
cians and BRPOs fearful of trial lawyers—so fearful that
mothers are given no choice or informed consent about
EFM. This medical paternalism supposedly died decades
ago, but apparently the reports of its death were greatly
exaggerated. As a recent author observed, although EFM is
almost certainly fatally flawed, “the overwhelming majority
of labor ing patients will continue to receive EFM, b eneficial or
not, in the foreseeable future.”50
Electronic Fetal Monitor and Medical Ethics:
Back to the Future
EFM was born during a period of perhaps the most rapid
advances in medical history, including advances in surgery,
medications, organ transplants, genetic engineering, repro-
ductive manipulations, and hundreds of technical advances
unimagined even a decade before. At the same time, social
and cultural changes stimulated philosophy and theology
scholars to join scientists and physicians in questioning the
ethical concerns of these rapid medical advances.51 During
the early part of this period in the late 1960s, the word
bioethics was coined as a way of linking scientific advances to
human values.51 By the end of the 1970s, bioethics was a new,
distinctive discipline with its own literature and its own
research centers, with professors of bioethics scattered
throughout the world’s medical schools.51
EFM’s birth and insertion into clinical practice occurred
before traditional deontology dramatically changed from the
revered Hippocratic-based benign paternalism—the physi-
cian’s duty to determine the best treatment for the patient
using only the physician’s best judgment—to the new, unfa-
miliar bioethics of autonomy—the patient’s freedom to decide
what is in her best interests—and autonomy’spartner,in-
formed consent.11,27–29,51 Side by side with autonomy
emerged two bioethics principles essentially similar to the
previous traditional medical ethics—beneficence (acting in
the patient’s best interest) and nonmaleficence (do no harm).
Among the new principles, autonomy and informed consent
were the absolute heart of bioethics, replacing the long-
revered, ancient Hippocratic instruction to physicians to do
what they thought was best for the patient, whether the
patient agreed or not.27–29,51 In fact, the Hippocratic tradition
was solely physician-centered, so much so that even such a
luminary as Oliver Wendell Holmes advised his 1871 medical
school graduate audience that patients had no right to the
medical truth of their condition.27 As jarring as that state-
ment may seem today, that was the mind-set of medical
ethics as EFM became popular—no need to discuss EFM with
mothers, obstetricians know exactly what to do and how to
do it. Unfortunately, that attitude has not changed even
slightly since the inception of EFM 50 years ago. And this
attitudinal truculence is intentional and willful. Through the
decades, BRPOs were well aware and were reminded often
that EFM was inefficacious, ineffectual, and useless for pre-
dicting CP or any other neurologic malady. Moreover, BRPOs
were periodically reminded that mothers should be given an
informed choice about EFM. BRPOs simply did not respond.
Even today, there remains no BRPO response. Nor has there
been any outcry from ethicists.
A Prophet Is Not without Honor
Only once in EFM’sandautonomy’s life, 1979, were serious
concerns raised in a high-profile National Institute of Child
Health (NICH) Task Force formed to investigate antenatal
diagnoses, including hereditary disease, congenital defects,
and intrapartum fetal distress predictors, one of which was
EFM. In its report, the task force emphasized that EFM was
unproven and had discernible risks and that data interpreta-
tion was problematic at best and likely responsible for the
already significant increa se in cesarean section. The task force
concluded that before EFM use, mothers were entitled to a
thorough discussion of benefits,limitations,andrisks,anda
choice of alternative forms of monitoring. The task force
pointedly observed that such discussions should occur during
prenatal care and again on admission to the labor suite.52,53
Nothing changed.
By 1984, the EFM lack of informed consent controversy
was prominent in the legal literature. The medical and legal
EFM issues were elegantly elucidated including EFM’s futility
and medicine’s failure to live up to the informed consent
autonomy where EFM use was concerned.54 Nothing
changed.
In 1987, the International Federation of Gynecology and
Obstetrics (IFGO), comprised of worldwide obstetrics–gyne-
cologic societies, published its guidelines for the use of fetal
monitoring. Echoing the 1979 NICH Task Force, the IFGO also
opined that mothers should have informed consent about
EFM use, both during antepartum care and again on admis-
sion to the labor suite.55 Nothing changed.
In 1987, the legal literature again emphasized obstetrics’
complete and total failure to include mothers in the EFM
discussion matrix, concluding that informed consent in ob-
stetrics was an illusion.56 Nothing changed.
Through the ensuing years, the same questions have been
raised and discussed and the same conclusions reached.57,58
Nothing changed. And because nothing has changed for half a
century, the questions continue to be raised even to this
day.59
Egregious Failure
This documented EFM ethical failure is egregious. There
have been failures of medical ethics in the past—the Tuske-
gee experiment, plutonium injections, mental health treat-
ments—and all had at least one common theme: the
subjects were not told about the experiment. Analogously,
mothers are not routinely told about the EFM experiment
inflicted in childbirth. And experiment is not too strong a
word. What word would accurately describe a medical
procedure indicted by its contemporaries for 50 years as
being a failure in every decade of its existence? EFM use has
done more harm than good and cost more in terms of
maternal morbidity and mortality than it has benefited
babies14,22; EFM interpretation today and in the past, even
The Surgery Journal
Perpetuating Myths, Fables, and Fairy Tales Sartwelle et al.
among experts, is subjective, impossible to standardize,
poorly reproducible, and contradictory20,33–35,37–39;there
are no long-term benefits of EFM1; fetal heart rate is a poor
measure of past and present fetal brain function and
damage10; 50 years of EFM and EFM-induced cesarean
sections have not changed the rate of CP or
encephalopathy1,8,10,12–15,17–24; as a screening test for
absence of injury, EFM is no better than a coin toss14;
EFM has a huge false-positive rate, a fact known since at
least 1979,52 and quantified at 99% in 1994, a percentage
never challenged since then6,9,11;nodataexistsinthe
entire medical literature demonstrating that any interven-
tion based on any single or combination of fetal heart rate
patterns reduces the risk of CP1,22,30;atestleadingtoan
unnecessary major abdominal surgery in 99.5% of cases
should be regarded by the medical community as absurd at
best22; an evolving consensus in the maternal–fetal medi-
cine community concludes it is time to start over with EFM
and establish common EFM language, standard EFM inter-
pretations, and EFM management principles and guilde-
lines30; EFM does not predict CP, neonatal neurologic
injury, stillbirth, or neonatal encephalopathy1,10;EFM
“harms women,”“wastes time and money,”and “offers
no lasting benefit”to children; and few physicians “would
use a pregnancy test (or a home smoke detector) that is
wrong almost every time a positive signal appears.”17
Homer Nods; Atlas Shrugs
The EFM experiment must end. It is past time to recognize
that EFM in labor is as much of a medical procedure with
potential, real life-and-death choices as any other significant
health care treatment. And it is far past time that mothers be
told the truth about EFM—it is still experimental. Many may
choose EFM. But the choice belongs to mothers, not physi-
cians and hospitals. The few voices from the distant and
recent past revealing EFM as an imposter and those calling
for informed consent have been intentionally disregarded by
BRPOs, physicians, and hospitals because they fear trial
lawyers and lawsuits more than they respect their ethical
obligations to mothers and babies. And although such fear is
neither rational, reasonable, nor ethical,6,9,11 at least it is a
discernible excuse for 50 years of medical paternalism. Eth-
icists, on the other hand, have no excuse whatsoever for their
silence.
Inthehalfcenturysincebioethicsbecameaconcept,
then a word, and finally reality, millions of spoken and
written words have championed autonomy—the individu-
al’s right to self-determination—as the heartbeat of bioeth-
ics. But, as so many point out, autonomy cannot possibly
exist without timely information.27–29,52–61 So the ques-
tion is, where have the ethicists been for almost a half
century as the EFM controversies over efficacy and in-
formed consent played out in the literature and in the
real world of childbirth? It is in that real world that
physicians and hospitals simply impose their modern-day
brand of medical paternalism. Did ethics sleep while the
medical world tilted on its axis?
Conclusion
Myths, fables, and fairy tales aside, medi cine has continued its
50-year use of a known scientifically bankrupt machine
under the banner that it is a reliable safety device monitoring
mothers’and babies’health. But EFM’s true purpose is
primarily to protect health care providers from trial lawyers;
with full knowledge that the machine causes harm to unsus-
pecting patients, its use is a shocking, flagrant, egregious
deception. The fact that only a handful of caregivers who
knew about the EFM deception tried over the years to change
the paradigm is equally shocking, but not nearly as appalling
as the fact that the entire medical ethics field did not listen,
much less endeavor to stop the open and obvious EFM patient
exploitation and duplicity. EFM’s half-century histor y is
simply undeniable proof that defensive medicine—postmod-
ern ethical relativism for physicians’sole benefit—easily
trumps the empty rhetoric of bioethics. Today is the day
that should end. If not now, when?
Recommendations
We recommend that an international task force similar to
the Neonatal Encephalopathy Task Force1publish a con-
sensus report stating the following: EFM cannot detect the
onset of neuropathology,10 cannot determine when neuro-
pathology would be reversible or irreversible,10 cannot
ascertain when earlier delivery by cesarean section would
prevent CP,10 and that except for obstetric catastrophes
(such as maternal cardiac arrest or uterine rupture), EFM
pattern interpretation does not reduce the risk of CP in any
population.6,10,11,22 Such a report would mark the begin-
ning of the end of using EFM pattern interpretation as the
standard of care in the world’s courtrooms.6,10,11,26 More
importantly, it would propel EFM clinical pattern interpre-
tation into the medical experimental category where it
belongs, thus requiring that mothersgive informed consent
before EFM use. Physicians would be able to continue using
EFM as a labor-saving device over one-on-one auscultation,
without the pressure to quickly deliver every baby with a
worrisome EFM pattern.
Funding
The authors received no financial support for the research,
authorship, or publication of this article.
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