Is CTG machines/ EFM necessary in mission hospitals in India?

(CTG-cardio-tocography. EFM-Electronic Fetal monitoring)

There is no real reason for anybody to listen to my ramblings but I would like ramble on anyway because I find that I am in a unique situation having worked as a consultant Obstetrician in rural hospitals without EFMs, followed by a stint in managing a busy labor unit in a tertiary level hospital with availability of EFM and again going back to rural mission hospitals. And also because you will be spending a large sum of money in buying an EFM machine and you need to know if what you get is well worth the money spent.

First let me quote from journals about electronic fetal monitoring. Most reviews about EFM say

                       – It is one modern medical intervention that was introduced into the market without prior randomized controlled trials.

But subsequent studies show that

                       -It does not decrease the perinatal deaths but increases the C-section  and operative vaginal delivery rates wherever it has been used. >250% without scalp pH and 30% with-in LSCS and >30% in operative vaginal deliveries)

                      - It has reduced the incidence of sudden intrapartum fetal deaths but that has not been statistically significant.

                      - There has been an increase in neonatal seizures when EFM is not used but these seizures are not associated with long term sequelae.

(Check RCM Evidence based practice for midwife-led care in labor 4^th edition and ACOG practice bullatin)

Second let me try to logically think through what you are trying to achieve with EFM and if EFM does what you except it to achieve.

Do you want EFM to diagnose fetal distress or avoid fetal distress?

If it is to avoid fetal distress than the next question is; is there a ‘pre fetal distress’ sign/pattern? The answer is NO. History and examination can do a better job of identifying a fetus at risk of developing fetal distress.

Does doing an admission test help in identifying this? NO.

Does EFM identify fetal distress? YES. But it also identifies a lot of other conditions which are not fetal distress and hence the high CS rates with the use of EFMs.

In the international classification of fetal heart rate patterns; Category 1 is when the fetal acid-base status is normal. Category 2 is when fetal acid-base status is unndetermined and Category 3 is when the fetal acid-base status was abnormal at the time of trace. In other words the fetal acid-base status may be abnormal temporarily and become normal spontaneously or with measure such as intrauterine resuscitation.

Abnormal fetal heart rate patterns include category 2 and category 3. On an average you will see category 2 trace 90% of the time compared to <1% of category 3 traces.(these figures are quoted randomly) Both of them warrant additional tests-in the case of category 2 to identify the actual fetal distress. And in category 3 to see if fetal distress is still present. Without these additional tests LSCS rates will be high making health care expensive for the individual woman and family and also to the country. It also adds significantly to chances of complications and maternal deaths. (Auxiliary tests for fetal wellbeing include VAST-vocal auditory stimulation test, Scalp stimulation and Scalp pH.)

Thirdly if EFM were doing their job well (identifying fetal distress) why would there be a continued search for better methods of identifying fetal distress? But we know that fetal pulse oxymetry and fetal ECG are being researched to replace EFM.

Fourthly; from my experience with working with and without EFMs- while at the remote rural hospitals I thot that it would be so wonderful to have a EFM when I was faced with meconium stained liquor (EFMs will be able to identify past dates requiring amnioinfusion from fetal distress); when faced with abruption or any other APH (to identify fetal distress early); and when faced with complication like eclampsia or fetal IUGR which is likely to lead to fetal distress.

But during my stint in tertiary level centre I found that LSCS was done for Meconium stained amniotic fluid (grade 2); for abruption irrespective of the stage and for women with eclampsia and IUGR. If we prescribe to the phrase ”action speaks louder than words” it would seem that the very people who use EFM do not believe that it would help them in identifying or avoiding fetal distress in these high risk conditions. (RCOG guidelines say that EFM if not the ideal method of fetal monitoring in low risk women but the ideal method of monitoring in high risk women is not known yet)

Finally having an EFM definitely blunts the ability to use your clinical acumen. Identifying scar dehiscence would be a wonderful use for EFM in mission hospitals. But even for this indication I found a strict adherence to selection of cases for trial of scar reduces the very incidence of scar dehiscence and scar rupture during labor.

As for use of EFM on those woman who are on oxytocin drip to identify fetal distress due to hyper stimulation-isn’t it logical to identify hyper stimulation itself? Isn’t it a better strategy to train nursing and medical students and staff in monitoring uterine contractions? Or is it that we can’t really be bothered to be a learning team caring for every aspect of managing a woman in labor? Because if your team cannot monitor a woman’s contractions;what are they doing in the labor room?!

Train your nursing and medical staff in decision making skills and skills in monitoring uterine contractions and listening to fetal heart sounds. Believe me it is a better option.