ArticlePDF AvailableLiterature Review

Abstract and Figures

A half century after continuous electronic fetal monitoring (EFM) became the omnipresent standard of care for the vastmajority 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.
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Content may be subject to copyright.
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:e23e28.
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 caregivershalf-century
misguided use of electronic fetal monitoring (EFM) and
cesarean sections (C-sections) to allegedly prevent cerebral
palsy (CP).1,2 The theoryEFM predicts CP and just-in-time
C-sections and prevents CP1,2has caused more harm than
good to mothers and babies35and 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 apologistDr. Max Wiznitzerwho defended
the current EFM-CP status quo in an ambush editorial8he
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. Pattersons and editorial staffsbias
for the CP-EFM status quo as well as their efforts to mufe
EFM-CP critics.
In 2014, JCN, led by a different editor, published the current
authorsarticleCerebral Palsy Litigation: Change Course or
Abandoned Ship9highlycritical of EFM and criticizing EFM-CP
litigation as a deceitful, money wasting sham on physicians
and the public. After Abandon Shipspublication, Dr. Patterson
took over JCN. He surreptitiously engaged WiznitzeraJCN
Editorial Board member and a child neurologistto write the
editorialas a reply to Abandon Ship. Dr. Patterson published
the editorial almost 2 years after Abandon Ships publication.
These authors received no notice of either the preparation of
the editorial or its publication. The editorialhid 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 editorialby submitting the
foregoing article to JCN in accordance with the usual instruc-
tions for authors. In reply, the authors received written
conrmation 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
scientic 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 justied as science, then perhaps
EFM use will continue. But the debate deserves open discus-
sion not suppression by partisan apologists.
The following article refutes Wiznitzerseditorialand
defends these authorscall for the abolition of EFM in labor as
well as in CP-EFM litigation. This article, contrary to the
editorial, relies on current scientic 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
scientic evidence justifying EFM use in most labors or in CP
litigation.17,912 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 Wiznitzers 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 conict of interest statement, he testies 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 signicant source of income, espe-
cially when he has testied since at least 1998.14 Wiznitzers
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
Wiznitzersjustication for current EFM use in virtually
every pregnancy and in CP litigationthe current status quo
is summarized in these confected arguments: EFM is
efcacious because it is widely used in the obstetrics
community; EFM has been investigated with resultant
publications; CP due to hypoxicischemic 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 unscientic1,3,912 but also has driven the C-sec-
tion rate to unprecedented levelsone-third of babies in the
United States and a quarter in the United Kingdom,1and
Australia,16 delivered by C-sectiondespite evidence that
EFM and cesareans have not altered in the least the rate of
CP,15,912 which was the primary aim of EFM,15nor 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-
agration1,6,9 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.1,37,1012,18 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
Wiznitzersrst argument is known by many namesargu-
mentum ad populum, bandwagon fallacy, appeal to popu-
larity, consensus fallacybut 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
communitys conventional wisdom was the belief in the
miasma theory and the imbalance of the bodysfour
humoursas the consensus cause of disease. When chal-
lenged by Semmelweissimple 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.2022 In this age of
evidence-based medicine, a modality like EFM should cer-
tainly not rest on a belief that it is efcacious 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 investigationshe claims exist.
Asignicant omission in the milieu of todays 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 scientic opinion based
solely on Painters 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 signicant undisclosed conicts of
interest,11,24,25 relied on anecdotes rather than clinical trials
to proveEFM efcacy.1,7,9,10,24,25 In 1975, a decade after
EFMsrst 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 scientically moti-
vated practitioners were using science to test EFMsunder-
lying theoryfetal 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 scientic 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 efcacious. Rather, the evidence proved exactly
what Benson27 and others said about EFM in the beginning:
birth asphyxia was a rare cause of CP;17,912,1719 EFM as a
predictor of CP was a myth;17,912,1719 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.15,7,912
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 scientic evidence.
So overwhelming is the evidence that a prestigious group of
maternalfetal 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 benet 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 benet and substantial
evidence of harm.4
So Wiznitzers statement that EFM has been investigated
and published is correct. His implication that the investiga-
tion resulted in a nding that EFM is scientic 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. EFMslackof
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.1,57,9,12
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,
rst counsels the readers not to use the HIE terminology
because neither hypoxia nor ischemia can be assumed to
have been the unique initiating mechanismof CP.17 Second,
NE 2014 warns the reader that the statistics are based on
studies where no two authors used the same neonatal
encephalopathy denition or criteria, thereby causing sig-
nicant 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 fewhave analyzed contempor-
ary data and CP causes.7,10,31
Ellenberg and Nelson published the rst CPasphyxia
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 specically 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 rst 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 identiable 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 prolic 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 scientic 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 writers veracity. And in this case, such trust would be
highly misplaced. Early in EFMs 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.3438
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
difcult 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 expertscan continue EFM
use exactly as they have from the beginning. The previous
studies may be underpowered, but is that a sufcient 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 scientic proof is pious, duplicitous, sanctimonious, and
hypocritical. Wiznitzer and FIGO need to join the Choosing
Wisely Canada initiative to nd 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 Monitorings 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 difcult in the extreme to determine what
Wiznitzer relies on for this assertion since EFMs biological
basis has been questioned from the beginning and through-
out its existence and proven false.14,7,912,1519,24,25,27,3032
More recently, it has been shown that fetal heart rate
decelerations, the heart of EFM orthodoxy, are commonly
associated with unthreading peripheral chemoreex rather
than fetal head or cord compression, the mainstay EFM
dogma for ve 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 EFMs biological basis prove
that EFM is not junk science. Thus, Wiznitzer claims that only
more research is needed to dene 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 Alices dialog with any of
the characters in Alices Adventures in Wonderland.
The EFM more research is neededcanard has been used
for most of EFMs 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 EFMs apotheosis was
the day of its rst 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
EFMs 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 KingdomsNational
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
signicant differences in CP, infant mortality, or other stan-
dard measures of neonatal well-being but demonstrated
signicant increases in caesarian sections and instrumented
deliveries.2
But the reduction in seizures is an ephemeral benet
because there have never been any long-term follow-up data
assessing the importance of this reduction.2Labeling seizure
reduction as an EFM benet,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
signicant? 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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The Surgery Journal Vol. 4 No. 1/2018
Continuous EFM during Labor Sartwelle, Johnstone28
... This trend continued in the search to mechanically understand, monitor and manageindeed controlthe phenomenon of birth. The example of the history of the ubiquitous fetal heart monitoring and cardiotochograph (CTG) instruments illustrate the development of this trend even though their use was questioned (Benson,1968;Blix et al., 2019;Sartwelle and Johnston, 2018). ...
... Studies in the medical journals Cochrane (Alfirevic, Devane and Gyte, 2013), PLOS ONE (Blix et al., 2019) showed similar results, highlighting the lack of benefits to either mother* or baby of the routine practice of cardiotochograph (CTG) used to inscribe contractions and fetal heart ratesand asking for the reconsideration of their use. Furthermore, Sartwelle and Johnston (2018) state that EFM (electronic fetal monitoring) "has done more harm than good to mothers and babies" and that there has been attempts to muffle evidence from medical research which resulted in numerous litigations: "Five decades of overwhelming evidence prove that it is not only unscientific, but also has driven the C-section rate to unprecedented levels" (Sartwelle and Johnston, 2018). C-Sections are a serious surgery that can "put women and babies at unnecessary risk of shortand long-term health problems if performed when there is not medical need" (WHO, 2021). ...
... Studies in the medical journals Cochrane (Alfirevic, Devane and Gyte, 2013), PLOS ONE (Blix et al., 2019) showed similar results, highlighting the lack of benefits to either mother* or baby of the routine practice of cardiotochograph (CTG) used to inscribe contractions and fetal heart ratesand asking for the reconsideration of their use. Furthermore, Sartwelle and Johnston (2018) state that EFM (electronic fetal monitoring) "has done more harm than good to mothers and babies" and that there has been attempts to muffle evidence from medical research which resulted in numerous litigations: "Five decades of overwhelming evidence prove that it is not only unscientific, but also has driven the C-section rate to unprecedented levels" (Sartwelle and Johnston, 2018). C-Sections are a serious surgery that can "put women and babies at unnecessary risk of shortand long-term health problems if performed when there is not medical need" (WHO, 2021). ...
Article
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Inscriptions on graph paper, on monitors and on various screens are ubiquitous in the birthing room; they reassure, worry, beep, light up and inform protocols. According to Latour (1985) their presence is not a result of a carefully planned logical choice, but of a legacy of mustering allies and convincing alignments. Using Barad's (2007) framework of agential realism, this paper explores the notion of intra-actions between objects and agencies of observation in the phenomenon of birth, using a socio-political and historical configuration. It presents some surprising accounts of obstetrics and gynaecology and showcases how historical inscriptions and instruments materialized today's birthing practices. It then presents how, upon entering the birthing room, one notices that the presence of instruments and inscriptions overshadows many other powerful actors at play. These other actors, such as atmosphere, presence, hormonal systems, memories, consciousness, relationship to pain, the sense of self are intangible and often not sufficiently attended to during childbirth even though literature shows their critical role for positive birth outcomes. Using post Actor Network Theory and medical scenographies (Neumann, 2021), this paper attempts to start an inquiry around the role of one of these intangible actors in the birthing room, namely the symphony of hormones (Odent, 2018), and explore their dynamic, porous, multiple nature (Mol, 2002; Neimanis, 2021). It then concludes by inquiring whether identifying the intra-actions of a fuller spectrum of actors in the room, both inscribed and intangible, invites the co-emergence (Ettinger, 2006) of new layers of actors and thus reconfigures the phenomenon of birth and its transformative potential.
... Uncomplicated birth is the latest in a series of terms, including normal birth, physiologic birth, and others, meant to draw attention to the overuse of unnecessary interventions during the perinatal period (Downe & Byrom, 2019). Overuse of cesarean is perhaps the most important of these (Boerma et al., 2018;Downe & Byrom, 2019;Sandall et al., 2018;Wiklund et al., 2018), but overuse of numerous additional medical technologies remains rampant, including induction of labor (Declercq et al., 2013;Seijmonsbergen-Schermers et al., 2020), continuous electronic fetal monitoring (Alfirevic et al., 2017;Sartwelle & Johnston, 2018), inaccurate diagnostic and prognostic tests (Faron et al., 2020), routine amniotomy (Declercq et al., 2013;Smyth et al., 2013), and many more (Downe & Byrom, 2019). The opposite idea is standard midwifery practice: most women can be supported to give birth without such interventions, and indeed they will have better outcomes without them. ...
... In other words, as hemorrhage prophylaxis during the third stage of labor, synthetic oxytocin might be another step in the cascade of obstetric interventions that is only necessary because of interventions used earlier in labor. It will be interesting to see how this specific issue plays out; as we have learned from other now-ubiquitous interventions in maternity care, once a clinical practice is widely adopted, it is difficult to divest ourselves of it even when evidence does not support its use, for example, routine screening ultrasound (Declercq et al., 2013;Ewigman et al., 1993;Siddique et al., 2009), and continuous electronic fetal monitoring (Alfirevic et al., 2017;Declercq et al., 2013;Sartwelle & Johnston, 2018). ...
Article
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of diversity in the maternity care workforce and commentaries on reviews focused on burnout in midwifery and a cross-national comparison of guidelines for uncomplicated childbirth.
... Banta and Thacker [6] argued this position in 1979, and again in 1990 [7]. In 2018, Sartwelle and Johnston [8] asserted that ongoing widespread use of intrapartum CTG monitoring was unethical, arguing that those who promote its use are using "junk science" (p. e24). ...
Article
Background International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women’s decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors. Aim To examine impacts of policy and research texts on midwives’ and obstetricians’ work with labouring women related to intrapartum fetal monitoring decision-making. Methods We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives’ and obstetricians’ work with the fetal monitoring system. Textual mapping was used to explain how midwives’ and obstetricians’ work was organised to happen the way it was. Findings CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour. Discussion and conclusion Guidelines structured midwives’ and obstetricians’ work in a manner that undermined women’s participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.
... As an example, over the past several years, our own work has focused on developing a new approach to EFM [101][102][103][104][105][106][107][108][109][110][111][112][113]. It has attacked the very poor performance metrics for EFM that even its own key opinion leaders admit and essentially proposed that various kinds of risk factors and uterine contraction frequency be used to contextualize EFM data and expand the clinical utility of EFM-based predictive models [114][115][116]. Conceptually, this should have been seen as a relatively minor change but with important impact, i.e., recognizing that the effectiveness of a technology might be conditioned by other factors [117][118][119][120]. Nevertheless, the resistance to even considering a new approach has been considerable, sometimes publicly including personal invectives even on paper. ...
Article
Advances in medical technology do not follow a smooth process and are highly variable. Implementation can occasionally be rapid, but often faces varying degrees of resistance resulting at the very least in delayed implementation. Using qualitative comparative analysis, we have evaluated numerous technological advances from the perspective of how they were introduced, implemented, and opposed. Resistance varies from benign - often happening because of inertia or lack of resources to more active forms, including outright opposition using both appropriate and inappropriate methods to resist/delay changes in care. Today, even public health has become politicized, having nothing to do with the underlying science, but having catastrophic results. Two other corroding influences are marketing pressure from the private sector and vested interests in favor of one outcome or another. This also applies to governmental agencies. There are a number of ways in which papers have been buried including putting the thumb on the scale where reviewers can sabotage new ideas. Unless we learn to harness new technologies earlier in their life course and understand how to maneuver around the pillars of obstruction to their implementation, we will not be able to provide medical care at the forefront of technological capabilities.
... El parto: El uso del monitor fetal electrónico para monitoreo continuo en partos de bajo riesgo jamás ha demostrado beneficio para una parturienta y un neonato, y de hecho aumenta los riesgos a la salud y vida de ambos, y sin embargo se ha convertido y continúa siendo el estándar de cuidado en la práctica obstétrica en partos hospitalarios (Gavrell 2021;Sartwelle 2018). Cambiar el estándar de cuidado, aunque ese estándar cause la muerte de más pacientes, es complicado, entre otras cosas porque el uso de tecnologías promueve la interpretación de las experiencias dentro de un contexto que se normaliza, y luego es difícil cambiar la percepción pública (Spector-Bagdady et al. 2017;Oberman 2017). ...
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Abstract: Copying science fiction, it has been proposed that anti-love biotechnology should be used to solve ethical problems: being in love should be conceived as a kind of addiction that, when harmful, should be “cured”. In this paper, I present and evaluate some aspects of the proposal to medicalize love. I show sexist assumptions in the conceptualization of problems and their solutions, and in medical practice; and argue that anti-love biotechnology will not solve the problems it aims to address. Using current examples of medicalized meaningful human experiences, I suggest the normalization of love-as-disease limits our imaginings of alternate futures: eventually it will be difficult to conceive of “being in love” as an experience free from medical control. The proposal to include “love-as-addiction” in the DSM-V also has the potential to undermine autonomy by laying the foundation to label as incompetent anyone in love and justify imposing treatment invoking medical paternalism. Keywords: (anti-)love biotechnology, medicalization, autonomy, sexism, human enhancement
... Tanto el uso de instrumentos como las cesáreas están correlacionados con más muertes de parturientas (Spector-Bagdady et al., 2007;Sartwelle, 2018). Actualmente, las gestantes en los Estados Unidos tienen más probabilidades de morir en el parto que las que tenían sus madres. ...
Article
Full-text available
Resumen: Recientemente, la violencia obstétrica ha sido reconocida como un problema de violencia de género que involucra una violación de los derechos de la mujer (ONU, 2019). En este artículo argumentamos que el uso rutinario de la episiotomía-una intervención quirúrgica que consiste en una incisión en el músculo del perineo-es un tipo de violencia obstétrica que se practica en Puerto Rico. La evidencia científica ha demostrado que la episiotomía rutinaria no tiene beneficios para una parturienta o un bebé, y que, al contrario, su práctica aumenta los riesgos de efectos adversos para la salud de una parturienta. Organizaciones como la OMS, la ACOG y la ONU recomiendan el uso de la episiotomía solamente si hay una indicación médica. A pesar de la evidencia científica y las recomendaciones, la episiotomía se practica rutinariamente en los partos bajo manejo obstétrico en los Estados Unidos. Aunque no tenemos estadísticas gubernamentales oficiales, los estudios sugieren que la episiotomía es una práctica obstétrica rutinaria en Puerto Rico. Antes de esta intervención quirúrgica usualmente no se obtiene consentimiento informado de las parturientas, en cuyo caso, según la ONU, se podría considerar "un acto de tortura y tratamiento inhumano y degradante" (2019, p. 11). Palabras claves: episiotomía, violencia obstétrica, violencia de género, derechos de la mujer, derechos humanos, ética médica, ética del parto, Puerto Rico Abstract: Recently, obstetric violence has been recognized as a gender violence problem that involves a violation of women's rights (ONU, 2019). In this paper, we argue that the routine use of episiotomy-a surgical procedure that consists of an incision in the perineal muscle-is a kind of obstetric violence that is practiced in Puerto Rico. Scientific evidence shows that routine use of episiotomy provides no benefit to a birthing woman or a baby, and that, on the contrary, it puts birthing women at increased risk of adverse health outcomes. Organizations such as the WHO, ACOG, and the UN recommend the use of the episiotomy only if it is medically indicated. Despite the scientific evidence and recommendations, episiotomy is routinely performed as part of the obstetric management of birth in the United States. Although we have no official Government statistics, studies suggest that episiotomy is a routine obstetric practice in Puerto Rico. Usually, there is no informed consent obtained before performing this surgical procedure, in which case,
... A very high proportion of obstetrical malpractice litigation has focused on whether an allegedly damaged baby developed CP because of mismanagement of labor and delivery or whether it was caused by events or conditions that preceded the onset of labor or came after birth [37]. A complete discussion of this issue is beyond the scope of this paper, but some salient concepts have been developed over the past several years. ...
Article
The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, even key opinion leaders admit that EFM has mostly failed to achieve this goal. We believe this situation emanates from a fundamental misunderstanding of differences between screening and diagnostic tests, considerable subjectivity and inter-observer variability in EFM interpretation, failure to address the pathophysiology of fetal compromise, and a tunnel vision focus. To address these suboptimal results, several iterations of increasingly sophisticated analyses have intended to improve the situation. We believe that part of the continuing problem is that the focus of EFM has been too narrow ignoring important contextual issues such as maternal, fetal, and obstetrical risk factors, and increased uterine contraction frequency. All of these can significantly impact the application of EFM to intrapartum care. We have recently developed a new clinical approach, the Fetal Reserve Index (FRI), contextualizing EFM interpretation. Our data suggest the FRI is capable of providing higher accuracy and earlier detection of emerging fetal compromise. Over time, artificial intelligence/machine learning approaches will likely improve measurements and interpretation of FHR characteristics and other relevant variables. Such future developments will allow us to develop more comprehensive models that increase the interpretability and utility of interfaces for clinical decision making during the intrapartum period.
... At this point, it seems clear that EFM is not a good predictor of fetal acidemia and its use has been criticized in various studies, with all the medical-law implications that it may have [23]. Total deceleration area and reperfusion time, have been shown to be superior predictors of fetal acidemia than ACOG III as independent parameters, although to achieve the best prediction they require association with other EFM, fetal or maternal variables. ...
Article
Objective The main objective is to study the predictive capacity of intrapartum total fetal reperfusion (fetal resilience) by itself or in combination with other parameters as a predictor of neonatal acidemia. Study design A retrospective case-control study was carried out at the Miguel Servet University Hospital (Zaragoza, Spain) on a cohort of 5694 pregnant women between June 2017 and October 2018. Maternal, perinatal, and cardiotocographic records were collected. Two reviewers blindly described the monitors with the American College of Obstetricians and Gynecologists (ACOG) categorizations and parameters and the non-ACOG parameters. Neonatal acidemia was defined as pH <7.10. The parameters analyzed to predict acidemia were evaluated using the sensitivity for specificity 90% value, and the area under the receiver operating characteristic curve. Results We recorded 192 infants with acidemia, corresponding to a global acidemia rate of 3.4%. Of these, 72 were excluded for lack of criteria, leaving 120 patients with arterial acidemia included in the study and 258 in the control group. The sensitivity (specificity 90%) of detection of acidemia was 42% for the ACOG III categorization (AUC, 0.524: 95% CI, 0.470–0.578), 24% for fetal reperfusion (AUC, 0.704: 95% CI, 0.649–0.759), 27% for total area of decelerations (AUC, 0.717: 95% CI, 0.664–0.771) and 50% for the multivariate model built from total reperfusion time (AUC, 0.826: 95% CI, 0.783–0.869). The total reperfusion time corresponding to a false negative rate of 10% is 23.75 min, with 28% of fetuses above this time. The AUC and sensitivity for a false negative rate of 10% are equivalent for deceleration area and time of reperfusion (p = .504). Conclusion The total reperfusion time (fetal resilience) and total deceleration area are non-ACOG parameters with a good predictive ability for neonatal acidemia, higher than the ACOG III classification and without statistical differences between them. The discrimination ability of total reperfusion time can be improved using a multivariate model. As a cutoff for its use we suggest 23.75 min in 30 min corresponding to an acidemic classification rate of 90%. New parameters in combination with other maternal, obstetrics, or fetal variables, are required for the interpretation of fetal well-being.
Article
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of how fetal monitoring may lead to overuse of birth-related interventions, commentaries on reviews focused on bedsharing, and women’s lifetime estrogen exposure and risk of cardiovascular mortality.
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An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of the WHO’s new Labour Care Guide and commentaries on reviews focused on prevention of mastitis in women during the postpartum period and a comparison of outcomes for fresh versus frozen embryos for in vitro fertilization.
Article
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Electronic fetal monitoring (EFM) was predicted by its inventors to be the long-sought cerebral palsy (CP) nemesis. Rather than prevent CP or any other birth problems, 40 years of EFM use has done substantial harm to mothers and babies and created a worldwide CP-EFM litigation industry that enriches only trial lawyers. Physicians, frightened by the ever-expanding and costly CP-EFM litigation crisis, and focused on avoiding lawsuits at all costs, embraced ethical relativism—charitably called defensive medicine— and continued EFM use even in the face of overwhelming evidence that EFM is merely junk science. In doing so, physicians completely abandoned the bedrock bioethics principles of autonomy, beneficence, and nonmaleficence. This daily ethical drama has played itself out for the past almost half century with little protest from obstetricians and no protest from ethicists. This article reviews EFM harms, the CP-EFM litigation crisis, and the resulting abandonment of bioethics principles and explores why the CP-EFM paradigm has failed utterly to follow the Kuhnian model of the scientific, technology, medical paradigm shift.
Article
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Background: Continuous electronic fetal heart-rate monitoring is widely used during labour, and computerised interpretation could increase its usefulness. We aimed to establish whether the addition of decision-support software to assist in the interpretation of cardiotocographs affected the number of poor neonatal outcomes. Methods: In this unmasked randomised controlled trial, we recruited women in labour aged 16 years or older having continuous electronic fetal monitoring, with a singleton or twin pregnancy, and at 35 weeks' gestation or more at 24 maternity units in the UK and Ireland. They were randomly assigned (1:1) to decision support with the INFANT system or no decision support via a computer-generated stratified block randomisation schedule. The primary outcomes were poor neonatal outcome (intrapartum stillbirth or early neonatal death excluding lethal congenital anomalies, or neonatal encephalopathy, admission to the neonatal unit within 24 h for ≥48 h with evidence of feeding difficulties, respiratory illness, or encephalopathy with evidence of compromise at birth), and developmental assessment at age 2 years in a subset of surviving children. Analyses were done by intention to treat. This trial is completed and is registered with the ISRCTN Registry, number 98680152. Findings: Between Jan 6, 2010, and Aug 31, 2013, 47 062 women were randomly assigned (23 515 in the decision-support group and 23 547 in the no-decision-support group) and 46 042 were analysed (22 987 in the decision-support group and 23 055 in the no-decision-support group). We noted no difference in the incidence of poor neonatal outcome between the groups-172 (0·7%) babies in the decision-support group compared with 171 (0·7%) babies in the no-decision-support group (adjusted risk ratio 1·01, 95% CI 0·82-1·25). At 2 years, no significant differences were noted in terms of developmental assessment. Interpretation: Use of computerised interpretation of cardiotocographs in women who have continuous electronic fetal monitoring in labour does not improve clinical outcomes for mothers or babies. Funding: National Institute for Health Research.
Article
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Given evidence that cerebral palsy is not reduced by electronic fetal monitoring, Karin Nelson, Thomas Sartwelle, and Dwight Rouse ask why routine monitoring and related litigation continue to contribute to high rates of caesarean births.
Article
Objective The objective of this study was to describe the incidence of baseline change within normal range during labor and its prediction of neonatal outcomes. Materials and Methods This was a prospective cohort of singleton, nonanomalous, term neonates with continuous electronic fetal monitoring and normal baseline fetal heart rate throughout the last 2 hours of labor. We determined baseline in 10-minute segments using Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria. We evaluated baseline changes of ≥ 20 and ≥ 30 bpm for association with acidemia (umbilical cord arterial pH ≤ 7.10) and neonatal intensive care unit (NICU) admission. Finally, we performed a sensitivity analysis of normal neonates, excluding those with acidemia, NICU admission, or 5-minute Apgar < 4. Results Among all neonates (n = 3,021), 1,267 (41.9%) had change ≥ 20 bpm; 272 (9.0%) had ≥ 30 bpm. Among normal neonates (n = 2,939), 1,221 (41.5%) had change ≥20 bpm. Acidemia was not associated with baseline change of any direction or magnitude. NICU admission was associated with decrease ≥ 20 bpm (adjusted odds ratio [aOR]: 2.93; 95% confidence interval [CI]: 1.19 – 7.21) or any direction ≥ 20 bpm (aOR: 4.06; 95% CI: 1.46–11.29). For decrease ≥ 20 bpm, sensitivity and specificity were 40.0 and 81.7%; for any direction ≥ 20 bpm, 75.0 and 58.3%. Conclusion Changes of normal baseline are common in term labor and poorly predict morbidity, regardless of direction or magnitude.
Chapter
Background: Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001. Objectives: To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour. Search methods: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies. Selection criteria: Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography. Data collection and analysis: Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy. Main results: We included 13 trials involving over 37,000 women. No new studies were included in this update.One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision. Authors' conclusions: CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.
Article
Although prematurity and hypoxic-ischaemic injury are well-recognized contributors to the pathogenesis of cerebral palsy (CP), as many as one-third of children with CP may lack traditional risk factors. For many of these children, a genetic basis to their condition is suspected. Recent findings have implicated copy number variants and mutations in single genes in children with CP. Current studies are limited by relatively small patient numbers, the underlying genetic heterogeneity identified, and the paucity of validation studies that have been performed. However, several genes mapping to intersecting pathways controlling neurodevelopment and neuronal connectivity have been identified. Analogous to other neurodevelopmental disorders such as autism and intellectual disability, the genomic architecture of CP is likely to be highly complex. Although we are just beginning to understand genetic contributions to CP, new insights are anticipated to serve as a unique window into the neurobiology of CP and suggest new targets for intervention.