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.

My unofficial stint as Obstetrician

So, between 1st August 1995 to 15th August 1995 (our maid arrived on the 12th and 15th being Independence day and a holiday I joined on 16th August officially), I was the unofficial Obstetrician on the campus! My husband was the only doctor and would do rounds and OPD during the day and attend all the calls during the nights.
In those 15 days/nights he'll come back from attending call and say ' there is a woman with transverse lie and hand prolapse with intrauterine death. We are waiting for the relatives to decide if they will donate blood then we'll do the CS.'
This was way back in 1995 when the AIDS scare had not stopped us from transfusing every woman who underwent LSCS. Many was the times, in fact more often than not, the family would refuse to donate blood and leave! And I remember counting 8 transverse lies in those 15 days! I also remember thinking                 " transverse lie again? I am sure my husband has made a mistake!" After all the woman wouldn't allow him to do the internal examination. The diagnosis was made by the nurse on duty. But a hand prolapse can't be missed!
During my entire 2 years as a PG registrar I had seen one transverse lie patient in labour! It had become such a rarity in South India that when I was an intern our consultant ran home to get his camera to take a picture of a 'hand prolapse'. And so in August 1995 I had in my carrier seen only 2 patients with transverse lie and actually never managed any of them. ( the senior most consultant managed/operated on these patients.) Talk about being a novice!
On the occasions when the relatives decided to donate blood and allow us to do the LSCS.........this is what happened.
 Ruby and Rasheeda were female ward attenders. Either of them would be on duty in the nights. And they would open the Operation room, prepare the patient( in those days shave the site and scrub with spirit), keep all the autoclaved instruments and drapes ready and call the scrub nurse and nurse anesthetist from their quarters and then come to our quarters and inform us that the patient has been shifted to the OR.
In the meanwhile when we knew that a patient had agreed to have the CS in the hospital, I used to feed the baby ( sometimes wake him and force him to feed) so that he won't wake up for feeds in the next hour.Then when Ruby or Rasheeda came and informed us that the patient was ready, both my husband and me would go to perform the C. section leaving the baby in their care. My husband, who was a pediatrician would give the spinal anesthesia and then  I would perform the CS and he will receive and look after the baby. And when both the mother( and baby) are fine we would return back to the quarters. Well over 1 1/2 - 2 hours later. And Ruby/Rasheeda would return to the hospital to wash the instruments and pack it again for autoclave while the sweeper cleaned the OR.
Leaving the house open with your precious child in the care of strangers was a bit scary in the beginning, but things worked out well.
        (In later life I learnt to perform the spinals my self and NEVER or very rarely performed LSCS for a dead baby) but that is what this blog is all about.

My arrival to rural North India.

I did my undergraduate training in Tamil Nadu, South India and after a 2 years period also completed my diploma in Obs and Gynae. Towards the end of my DGO, I married one of my classmates,who was very keen on working in Rural North India. So, in 1995 when our first son was 45 days old I traveled to Kanpur by train, a 48 hour long journey! My husband who had joined 3 months earlier was at the station to receive us. And then we traveled by the hospital jeep for another 2 hours to reach the hospital in Fathepur.
This was my first time in North India!
And my first impression of North India?.......... It was beautiful, the ride from Kanpur to Fathepur was beautiful. It was in August and the monsoon was in full swing. The weather was pleasant and the fields green. There were wild peacock in the fields adding vibrant color to the scene.
When we reached the hospital my husband broke the news that the other lady doctor who worked there had gone on leave and was to have returned a week ago but had not returned. That meant I was the only 'lady doctor' on the campus. That would mean cutting my maternity leave short and getting down to work!
But fortunately for me, the servant who was to have traveled with us(my parents accompanied me)  missed the train and so I need not officially join duty till we found a maid. ( For people from countries where having maids is strange- Most women in India can not put in their best if it was not for maids who looked after their children while they worked.) I am ever grateful for these servants who have helped raising my children.