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Continuous Electronic Fetal Monitoring during
Labor: A Critique and a Reply to Contemporary
Proponents
Thomas P. Sartwelle, BBA, LLB1James C. Johnston, MD, JD2
1Deans and Lyons, LLP, Houston, Texas
2Global Neurology Consultants, USA and Auckland, New Zealand
Surg J 2018;4:e23–e28.
Address for correspondence James C. Johnston, MD, JD, 1150 N Loop
1604 W, Suite 108 San Antonio, Texas 78248
(e-mail: johnston@GlobalNeurology.com).
Prologue
Four centuries ago, the Catholic Church declared heliocentr-
ism to be heretical, banned all heliocentric books, and
ordered Galileo to refrain from holding, teaching, or defend-
ing heliocentric ideas. A similar effort is taking place today. It
seeks to suppress debate over birth caregivers’half-century
misguided use of electronic fetal monitoring (EFM) and
cesarean sections (C-sections) to allegedly prevent cerebral
palsy (CP).1,2 The theory—EFM predicts CP and just-in-time
C-sections and prevents CP1,2—has caused more harm than
good to mothers and babies3–5and has resulted in decades-
long, worldwide EFM-CP litigation that has reached a crisis of
near epidemic proportions,6costing tens of millions
annually.1,6,7
The following article has its genesis in exposing an EFM-
CP litigation apologist—Dr. Max Wiznitzer—who defended
the current EFM-CP status quo in an ambush “editorial”8he
authored by special invitation from the current editor
Dr. Marc Patterson and senior editorial staff of the Journal
of Child Neurology (JCN). This special invitation and the
editorial exposed Dr. Patterson’s and editorial staff’sbias
for the CP-EFM status quo as well as their efforts to muffle
EFM-CP critics.
In 2014, JCN, led by a different editor, published the current
authors’article—Cerebral Palsy Litigation: Change Course or
Abandoned Ship9—highlycritical of EFM and criticizing EFM-CP
litigation as a deceitful, money wasting sham on physicians
and the public. After Abandon Ship’spublication, Dr. Patterson
took over JCN. He surreptitiously engaged Wiznitzer—aJCN
Editorial Board member and a child neurologist—to write the
“editorial”as a reply to Abandon Ship. Dr. Patterson published
the editorial almost 2 years after Abandon Ship’s publication.
These authors received no notice of either the preparation of
the editorial or its publication. The “editorial”hid from JCN
readers the fact that Wiznitzer was a JCN editorial Board
member and career expert witness,and the editor also allowed
Wiznitzer to engage in unprovoked, spurious personal attacks
on these authors. The editorial, as will be seenfrom this article,
is so lacking in scholarship and references that it is virtually
certain that it was not peer-reviewed.
These authors replied to the “editorial”by submitting the
foregoing article to JCN in accordance with the usual instruc-
tions for authors. In reply, the authors received written
confirmation that the article “is presently being given full
consideration for publication in the Journal of Child Neurol-
ogy.”JCN, as does any legitimate medical journal, promises
Keywords
►electronic fetal
monitoring
►cerebral palsy
►medical ethics
►journal of child
neurology
►Dr. Max Wiznitzer
►Dr. Marc Patterson
Abstract A half century after continuous electronic fetal monitoring (EFM) became the
omnipresent standard of care for the vast majority of labors in the developed countries,
and the cornerstone for cerebral palsy litigation, EFM advocates still do not have any
scientific evidence justifying EFM use in most labors or courtrooms. Yet, these EFM
proponents continue rationalizing the procedure with a rhetorical fog of meaningless
words, misleading statistics, archaic concepts, and a complete disregard for medical
ethics. This article illustrates the current state of affairs by providing an evidence-based
review penetrating the rhetorical fog of a prototypical EFM advocate.
received
October 23, 2017
accepted after revision
January 12, 2018
DOI https://doi.org/
10.1055/s-0038-1632404.
ISSN 2378-5128.
Copyright © 2018 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
THIEME
Review Article e23
“ALL submissions (including invited material) are subjected
to peer review.”
But Dr. Patterson, the same JCN editor who surreptitiously
planned and executed the ambush “editorial,”unilaterally
refused to submit the manuscript to peer review despite
informing the authors for months that the manuscript was
undergoing routine peer review. Finally, Dr. Patterson simply
e-mailed a rejection 4 months after submission, stating that
all discussion of the topic “is now closed.”
The hallmark of real science is submitting existing para-
digms to the crucible of vigorous debate. If CP-EFM use in
labor and litigation can be justified as science, then perhaps
EFM use will continue. But the debate deserves open discus-
sion not suppression by partisan apologists.
The following article refutes Wiznitzer’s“editorial”and
defends these authors’call for the abolition of EFM in labor as
well as in CP-EFM litigation. This article, contrary to the
editorial, relies on current scientific research and facts to
support these arguments. The question is: can proponents of
continuing the current EFM paradigm for labor and litigation
do the same?
The Fog of Rhetoric
A half century after continuous EFM became the omnipre-
sent standard of care for the vast majority of labors in the
industrialized world,1,3,9 and became the cornerstone for
EFM-CP litigation,1,3,6,9 EFM proponents still have no valid
scientific evidence justifying EFM use in most labors or in CP
litigation.1–7,9–12 Nevertheless, EFM proponents continue
rationalizing EFM use in labor and courtrooms with a rheto-
rical fog of misleading statistics, meaningless words, and
reliance on concepts as archaic as the miasma theory of
diseases.
Emblematic of this rhetorical fog is a recent “editorial”
defending past and current EFM use as science, championing
its litigation use to unjustly convict birth caregivers of
causing CP and rationalizing continued EFM-induced unne-
cessary C-sections causing harm to mothers and babies, with
the half-century-old bromide that “more research is
needed.”8
This article will penetrate the rhetorical fog of this latest
EFM apologist and others advocating continued EFM use
despite the overwhelming evidence of its uselessness in
labor and its junk science status in litigation.
Motivation
A cursory review of Wiznitzer’s editorial8makes it seem as if
it was prompted by his altruistic, academic desire to defend
EFM from the courtroom junk science label. In reality, the
junk science label is of special concern to him because, as
disclosed in his conflict of interest statement, he testifies for
money in encephalopathy lawsuits.8What he failed to dis-
close, however, was his 2015 testimony under oath that he
spends 4 to 5 hours per week in paid litigation.13 Almost
300 hours per year is a significant source of income, espe-
cially when he has testified since at least 1998.14 Wiznitzer’s
real motive, therefore, would seem to be protecting his EFM-
CP litigation testimony from attack as junk science and
possibly being struck as a witness in forthcoming trials.15
Wiznitzer’sjustification for current EFM use in virtually
every pregnancy and in CP litigation—the current status quo
—is summarized in these confected arguments: EFM is
efficacious because it “is widely used in the obstetrics
community”; EFM has been “investigated with resultant
publications”; CP due to hypoxic–ischemic encephalopathy
(HIE) occurs in 1 to 4 per 10,000 live births; animal and
human studies show correlation between EFM changes and
fetal acidemia; clinical trials between EFM and intermittent
auscultation (IA) to detect CP were underpowered and could
not detect differences in that outcome; EFM has a biological
basis supporting its continued use; and intensive EFM train-
ing in a few limited studies resulted in improved neonatal
outcomes.8
These arguments will be examined against the back-
ground of EFM-CP research and experience.
Is Electronic Fetal Monitoring Junk Science?
Five decades of overwhelming evidence prove that EFM is
not only unscientific1,3,9–12 but also has driven the C-sec-
tion rate to unprecedented levels—one-third of babies in the
United States and a quarter in the United Kingdom,1and
Australia,16 delivered by C-section—despite evidence that
EFM and cesareans have not altered in the least the rate of
CP,1–5,9–12 which was the primary aim of EFM,1–5nor has it
altered the rates of perinatal death,1,2 neonatal death,1,2
intrapartum stillbirth,1,2 low or very low Apgar scores, need
for special neonatal care,1,2 or the rate of neonatal
encephalopathy.1,2,17
While EFM failed as a medical appurtenance to birth, EFM
use did produce the ongoing worldwide CP litigation con-
flagration1,6,9 with the counterfeit foundation that EFM
predicts and prevents CP, and EFM-inspired just-in-time C-
sections save babies from a lifetime of CP and other neuro-
logic devastation.1,3–7,10–12,18 CP litigation, in turn, inspired
physicians to compromise their ethical principles, using EFM
without informed consent as protection from CP lawsuits
despite the evidence that EFM has caused more harm than
good.9,11,18,19
Widely Used in the Obstetrics Community
Wiznitzer’sfirst argument is known by many names—argu-
mentum ad populum, bandwagon fallacy, appeal to popu-
larity, consensus fallacy—but is a poor substitute for medical
evidence. One may as well argue that since millions of people
worldwide still smoke, smoking must be healthy despite the
contrary medical evidence. And not so long ago, the medical
community’s conventional wisdom was the belief in the
miasma theory and the imbalance of the body’s“four
humours”as the consensus cause of disease. When chal-
lenged by Semmelweis’simple hand washing to prevent
puerperal fever, the collective medical community rejected
the idea outright for almost a half century.
The Surgery Journal Vol. 4 No. 1/2018
Continuous EFM during Labor Sartwelle, Johnstone24
There are hundreds of other past and current examples of
widely held medical community fallacies.20–22 In this age of
evidence-based medicine, a modality like EFM should cer-
tainly not rest on a belief that it is efficacious merely because
it “is widely used in the obstetrics community,”8especially
when multiple lives are at risk as in labor and delivery.
Electronic Fetal Monitoring Investigated
and Published
Wiznitzer argues that EFM is science because EFM has been
investigated and the investigations have been published.8
But Wiznitzer asks readers to have faith and trust in his
statement on his say-so alone because he provides no cita-
tions to any of the published “investigations”he claims exist.
Asignificant omission in the milieu of today’s evidence-
based medicine, reminiscent of days gone by when noted
American zoologist Theophilus Painter in 1923 declared that
humans had 24 pairs of chromosomes. Until 1955, this
erroneous concept was consensus scientific opinion based
solely on Painter’s unquestioned authority.23 Wiznitzer fails
to cite articles supporting EFM as science because there are
no contemporary articles supporting that statement.
EFM was invented in the hope of identifying fetal
asphyxia, which was thought to be the cause of CP.1,3,10
EFM inventors, with significant undisclosed conflicts of
interest,11,24,25 relied on anecdotes rather than clinical trials
to “prove”EFM efficacy.1,7,9,10,24,25 In 1975, a decade after
EFM’sfirst clinical use but before EFM was subjected to even
one clinical trial, advocates contended that EFM alone would
reduce by half intrapartum deaths, mental retardation, and
CP.26
ButevenasEFMwasbecomingthestandardofcare
despite a lack of clinical trials, more scientifically moti-
vated practitioners were using science to test EFM’sunder-
lying theory—fetal heart rate patterns predict fetal distress
(asphyxia) and acidosis.7,24,25 Benson et al, studying
25,000 labors, concluded there was no single reliable fetal
heart rate indicator of fetal distress,27 whereas others
demonstrated that most fetal heart rate patterns deemed
abnormal were associated with normal cord pH, and even
the most dramatic patterns resulted in very few neonates
born acidotic.4,24,25 The obstetrical community ignored
these studies, purposely using unproven EFM technology
in an age when medical technology seemed to have
bypassed obstetrics in favor of every other medical
specialty.9,11,18,24,25
For the next half century, the scientific and medical
evidence related to CP and EFM accumulated at a rapid
pace. At the same time, EFM use increased to 85% of all
labors in the United States and similar numbers in other
industrialized cou ntries.7,9,12,28 The rate of C-sections world-
wide also rose substantially.1Today, C-sections are used to
deliver one-third of babies born in the United States and
similar percentages in other countries,1,4,16,28 rates that
exceed the rate needed to minimize morbidity and
mortality.29
But like an O. Henry short story, the EFM saga has a plot
twist and a surprise ending. The accumulated CP-EFM evi-
dence did not prove asphyxia as a prominent CP cause or that
EFM was efficacious. Rather, the evidence proved exactly
what Benson27 and others said about EFM in the beginning:
birth asphyxia was a rare cause of CP;1–7,9–12,17–19 EFM as a
predictor of CP was a myth;1–7,9–12,17–19 EFM inspired C-
sections caused more harm tha n good;4,5,9 and the rate of CP,
despite EFM and C-sections, was unchanged, as were rates of
perinatal death, intrapartum stillbirth, neonatal death, low
or very low Apgar scores, need for special neonatal care, and
neonatal deaths.1–5,7,9–12
The more incredible par tof this O. Henry ending is the fact
that this accumulated evidence is virtually unchallenged by
any substantial contemporary medical or scientific evidence.
So overwhelming is the evidence that a prestigious group of
maternal–fetal medicine specialists have advocated that it is
time to start over with EFM and establish common language,
standard interpretation, and reasonable management prin-
ciples and guidelines.30 The obstetrical societies of the
Australia, Canada, New Zealand, and the United States,
assessing the CP-EFM evidence, agree that EFM provides no
long-term benefit for children.17 Since 2001, Cochrane Data-
base of Systematic Reviews has reviewed EFM four times,
each time concluding that there is no difference between
EFM monitoring and IA (with one parameter discussed later)
except that the C-section rate with EFM is substantially
higher.2The United States Preventive Services Task Force
gave EFM a D grade, the worst that can be given, concluding
that there was no evidence of EFM benefit and substantial
evidence of harm.4
So Wiznitzer’s statement that EFM has been investigated
and published is correct. His implication that the investiga-
tion resulted in a finding that EFM is scientific is so wrong as
to be intentionally dishonest.
Cerebral Palsy due to Hypoxic Ischemic
Encephalopathy
Wiznitzer begins discussing HIE with a demonstrably false
premise: “In order to determine whether studies of the use
of electronic fetal monitoring in LESSENING the cerebral
palsy rate have reached valid conclusions, an understanding
of the epidemiology of cerebral palsy is needed.”8[empha-
sis added]. There is no published study concluding that EFM
has ever lessened the CP rate, just the opposite. EFM’slackof
effectiveness in preventing CP is consistent: Since 1970
when EFM became the default standard of care, and
C-sections the misguided rescue procedure for supposed
fetal distress-asphyxia, the world rate of CP has remained
unchanged.1,5–7,9,12
From this false premise, Wiznitzer cites statistics from
Neonatal Encephalopathy 2014 (NE 2014)17 ending with a
calculation that 10 to 20% of CP is due to HIE, a rate of 1 to 4
per 10,000 live births.8This calculation, however, seems
rather bizarre because it does not lead to any relevant
conclusion.
The Surgery Journal Vol. 4 No. 1/2018
Continuous EFM during Labor Sartwelle, Johnston e25
Perhaps more telling, t he source for the statistics, NE 2014,
first counsels the readers not to use the HIE terminology
because “neither hypoxia nor ischemia can be assumed to
have been the unique initiating mechanism”of CP.17 Second,
NE 2014 warns the reader that the statistics are based on
studies where no two authors used the same neonatal
encephalopathy definition or criteria, thereby causing sig-
nificant terminological confusion and misuse of the various
statistics.17
One wonders why Wiznitzer uses stale, misleading, out-
dated data and terminology when several contemporary
articles by highly visible, respected, original CP researchers
—Jonas Ellenberg, Karin Nelson, Nadia Badawi and Alastair
MacLennan, to name just a few—have analyzed contempor-
ary data and CP causes.7,10,31
Ellenberg and Nelson published the first CP–asphyxia
analysis in a 1986 landmark article, concluding that the
proportion of CP reasonably attributable to birth asphyxia
was less than 10%.32 Revisiting the issue in 2013, they
analyzed the literature published since their 1986 article.
Their conclusion: “The current data do not support the belief,
widely held in the medical and legal communities, that birth
asphyxia can be recognized reliably and specifically on the
basis of clinical signs such as aberrant fetal heart rate
patterns, Apgar scores, respiratory depression, neonatal
seizures, or acidosis, or that most CP is due to birth
asphyxia.”31
Badawi, an internationally recognized CP researcher, and
among the first to conduct reliable research on CP causes,
also analyzed the causal pathways to CP, observing that most
term infants with CP seem normal at birth. Only 25% of term
infants in the Western Australia Newborn Encephalopathy
study who develop CP had neonatal enceph alopathy, and 29%
had identifiable intrapartum risk factors, of whom 24% had
both antenatal and intrapartum risk factors and only 5% had
solely intrapartum risk factors.7
MacLennan, also an internationally recognized Australian
CP researcher and prolific author, in a 2015 article that
should have been available to Wiznitzer, concluded that
the origin of most CP is prior to labor and is due to a host
of causes and pathways including up to 31% due to genetic
variants.10,33
It is indeed bizarre that Wiznitzer never mentions these
international icons of CP research whose research has domi-
nated the medical journals for decades.
Electronic Fetal Monitoring and Acidemia
Wiznitzer apparently believes that EFM is scientific because
“animal and human studies showed a correlation between
EFM changes and fetal acidemia.”8Again, with no citation to
support the statement, the reader is back to having to trust
the writer’s veracity. And in this case, such trust would be
highly misplaced. Early in EFM’s life, it was well known that
most EFM patterns thought to be abnormal were associated
with normal cord pH, and even with dramatic patterns, a
very small proportion of neonates were born acidotic.4And
despite whatever animal and human studies Wiznitzer may
have read, contemporary efforts to correlate EFM patterns
with neonatal acidemia have failed.34–38
Previous Electronic Fetal Monitoring Studies
Underpowered
The underpowered studies argument is a familiar one.
Wiznitzer seems to have been inspired in this argument by
the 2015 International Federation of Gynecology and Obste-
trics (FIGO) Consensus Guidelines on Intrapartum Fetal
Monitoring,39 which made the exact same argument: EFM
and IA comparative studies, undertaken in the 1970s, 1980s,
and early 1990s, were underpowered to detect differences in
CP and other major outcomes, and therefore the results are
difficult to relate to current practice,8the thought being that
current-day physicians should ignore these studies. FIGO
stated it plainly: most experts believe that EFM should
continue to be used.39 The number representing “most”
was unstated.
This argument is simply a canard, an easily destroyed
straw man, made so that “most experts”can continue EFM
use exactly as they have from the beginning. The previous
studies may be underpowered, but is that a sufficient ratio-
nalization to continue EFM use? The question unanswered by
FIGO and Wiznitzer is: where are the studies justifying
continued EFM use? In this day of evid enced-based medicine,
the argument that most experts favor its use as a substitute
for scientific proof is pious, duplicitous, sanctimonious, and
hypocritical. Wiznitzer and FIGO need to join the Choosing
Wisely Canada initiative to find what medi cal “activities t hat,
based on evidence, we should not be doing and then try not
doing those things. By doing less, not more, we will spare
patients harm and can free up resources for what is really
helpful.”40
Electronic Fetal Monitoring’s Biological
Basis
Wiznitzer claims that EFM has a biological basis and, when
used as part of an ongoing quality improvement program,
results in improved neonatal outcomes.8Again, however,
there are no citations supporting the biological basis state-
ment (the quality improvement statement is refuted in the
next section). It is difficult in the extreme to determine what
Wiznitzer relies on for this assertion since EFM’s biological
basis has been questioned from the beginning and through-
out its existence and proven false.1–4,7,9–12,15–19,24,25,27,30–32
More recently, it has been shown that fetal heart rate
decelerations, the heart of EFM orthodoxy, are commonly
associated with unthreading peripheral chemoreflex rather
than fetal head or cord compression, the mainstay EFM
dogma for five decades.41
Electronic Fetal Monitoring Quality
Improvement Programs
Wiznitzer cites four articles8(2006, 2009, 2014, 2015)
involving intensive EFM pattern recognition and
The Surgery Journal Vol. 4 No. 1/2018
Continuous EFM during Labor Sartwelle, Johnstone26
communication training programs resulting in what were
said to be improved neonatal outcomes, albeit the improve-
ments were temporary and went away if the intense training
stopped. The so-called improvements were also question-
able as the criteria for what were called “improved results”
are subjective and elusive.
The most important and recent of these studies recog-
nized several shortcomings for this type of study, not the
least of which was that the improvements gained were for
short-term neonatal outcomes. These authors cautioned that
there was little correlation between the outcomes examined,
and neonatal encephalopathy and other long-term adverse
sequelae of labor.42
Despite these shortcomings, Wiznitzer contends that
these studies combined with EFM’s biological basis prove
that EFM is not junk science. Thus, Wiznitzer claims that only
“more research is needed to define the use of electronic
monitoring in appropriate target populations, in determina-
tion of neonatal outcome, in utilization with other measures
of fetal functioning, and in quality improvement and educa-
tion programs.”8This passage is the typical rhetorical fog that
EFM proponents resort to because they have no evidence.
The sentence has no meaning. It could be used in a dic tionary
to illustrate words such as obtuse, nonsense, nonsequitur,
inane, vacuous, and orthogonal. It could easily have been
written by Lewis Carroll as part of Alice’s dialog with any of
the characters in Alice’s Adventures in Wonderland.
The EFM “more research is needed”canard has been used
for most of EFM’s clinical life to justify continued EFM use
despite the known harm it caused to mothers and
babies.9,11,18,25,28 In view of the known EFM harms, it is
time for obstetrics to recognize that EFM’s apotheosis was
the day of its first clinical use. Fifty years of EFM research has
only brought EFM to the point where all but EFM zealots
recognize it is time to start over.1,4,9,10,19,30
In fact, many in the obstetrical world have recognized
EFM’s harms, contrary to Wiznitzer and his ilk, and tried to
reduce its impact on at least low-risk pregnancies. In the
forefront of this effort has been United Kingdom’sNational
Institute for Health and Care Excellence (NICE). Since 2001,
NICE has slowly reduced EFM use and has for many years
recommended to not use EFM in normal pregnancies.43
Recently, ACOG made similar recommendations.44 Recogniz-
ing that EFM was introduced as a substitute for IA but that
EFM has not reduced perinatal death or CP, but has substan-
tially increased the numbers of C-sections and instrumented
vaginal deliveries, ACOG now recommends that women with
low-risk pregnancies be given an informed choice between
IA and EFM.44
Electronic Fetal Monitoring Reduces
Seizures?
The only EFM red herring Wiznitzer did not use as a
rationalization for continued EFM use was that EFM use
reduces neonatal seizures. It is true that the EFM versus IA
clinical trials that EFM proponents claim were underpow-
ered and therefore useless have shown a reduction in neo-
natal seizures.2These same trials have also demonstrated no
significant differences in CP, infant mortality, or other stan-
dard measures of neonatal well-being but demonstrated
significant increases in caesarian sections and instrumented
deliveries.2
But the reduction in seizures is an ephemeral “benefit”
because there have never been any long-term follow-up data
assessing the importance of this reduction.2Labeling seizure
reduction as an EFM “benefit,”therefore, is simply grasping
at nonexistent straws. Importantly, a ssuming a seizure risk of
approximately 3 per 1,000, it is estimated that 667 women
must be subjected to continuous EFM monitoring to prevent
one seizure. And of the 667 women so monitored, 15 would
have C-sections.2
Conclusion
Fifty years of EFM use has resulted in more harm than good to
mothers and their children. When it comes to labeling a
medical modality “junk science,”is there any criteria more
significant? Medical research frequently reveals some long-
held belief to be obsolete or even harmful, and it is discarded.
EFM has been harmful for almost its entire existence, yet EFM
apologists like Wiznitzer and others continue to obfuscate the
truth with their rhetorical fog of stale facts and willfully ignore
EFM harms, insisting that EFM is a viable medical tool. Why?
The answer to this question is elusive at best and lays
somewhere in the collective unconscious mind of EFM
zealots. As Churchill said of Russia, it is a riddle wrapped
in a mystery inside an enigma.
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