DOI: 10.1097/JPN.0000000000000035
C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins J Perinat Neonat Nurs r Volume 28 Number 2, 135–143 r Copyright
Consumer Information on Fetal Heart Rate Monitoring During Labor: A Content Analysis A Content Analysis Jennifer Torres, PhD; Raymond De Vries, PhD; Lisa Kane Low, PhD, CNM, FACNM ABSTRACT Electronic fetal monitoring (EFM) is used for the majority of births that occur in the United States. While there are indications for use of EFM for women with high-risk pregnancies, its use in low-risk pregnancies is less evidencebased. In low-risk women, the use of EFM is associated with an increased risk for cesarean birth compared with the use of intermittent auscultation of the fetal heart rate. The purpose of this investigation was to evaluate the existence of evidence-based information on fetal heart rate monitoring in popular consumer-focused maternity books and Web sites. Content analysis of information in consumeroriented Web sites and books was completed using the NVivo software (QRSinternational, Melbourne, Australia). Themes identified included lack of clear terminology when discussing fetal monitoring, use of broad categories such as low risk and high risk, limited presentation of information about intermittent auscultation, and presentation of Author Affiliations: Department of Sociology (Dr Torres), Center for Bioethics, Department of Graduate Medical Education, School of Medicine (Dr De Vries), and School of Nursing; and Department of Women’s Studies (Dr Low), University of Michigan, Ann Arbor. Funding for this project was received from the Institute for Research on Women and Gender and the CUBE program, University of Michigan. The authors thank the members of the University of Michigan CUBE funded project: Examination of the clinical and non-clinical factors influencing use of electronic fetal monitoring, Sonya Dal Cin, Scott Greer, and Denise Lillvis. Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Lisa Kane Low, PhD, CNM, FACNM, School of Nursing and Department of Women’s Studies, University of Michigan, 400 N Ingalls, Ste 3320, Ann Arbor, MI 48109 ([email protected]). Submitted for publication: January 9, 2014; accepted for publication: February 26, 2014. The Journal of Perinatal & Neonatal Nursing
EFM as the standard of care, particularly upon admission into the labor unit. More than one-third of the sources did not mention auscultation, and conflicting information about monitoring methods was presented. The availability of accurate, publically accessible information offers consumers the opportunity to translate knowledge into the power to seek evidence-based care practices during their maternity care experience. Key Words: consumer publications, electronic fetal monitoring, evidence-based practice, intermittent auscultation
urrently, in the United States, the predominant method of fetal assessment during labor is the use of electronic fetal monitoring (EFM).1 When EFM was introduced in the 1960s, anticipated improvements in neonatal outcomes and reduction of fetal acidemia were assumed.2,3 Instead, the use of continuous EFM has not been shown to improve perinatal outcomes compared with intermittent auscultation of the fetal heart rate (IAFHR) when used in low-risk women.4,5 Furthermore, there is evidence that the overuse of EFM for low-risk women increases the incidence of cesarean birth when compared with IAFHR.5 In recognition of the limited evidence to support generalized use of EFM for all women, guidelines from professional organizations indicate that IAFHR is as safe as EFM as a method of assessing fetal well-being in women who are at term and have no other obstetric or medical risk factors that increase the risk for fetal acidemia during labor.6–8 Given this conclusion, it is unclear why EFM continues to be used for most women experiencing a lowrisk pregnancy and birth. There are a number of factors that contribute to the use of EFM as the dominate
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method. Women can access information about fetal assessment during labor, and the use of IAFHR and EFM is often reviewed in childbirth education classes so that they can make informed choices about fetal assessment during labor. However, it is possible that women are knowledgeable about IAFHR as an evidence-based intervention that may promote normal birth and reduce the risk for interventions such as cesarean birth. Therefore, the purpose of this article was to evaluate the availability and quality of consumer information on EFM within 2 publicly available sources: maternity Web sites and consumer-oriented books.
BACKGROUND Listening to Mothers III, a survey of women in the United States who gave birth in 2011-2012, indicated that 89% of women were monitored with continuous EFM.1 However, when compared with IAFHR, EFM does not reduce the overall risk of perinatal death (relative risk [RR] = 0.85; 95%; confidence interval [CI], 0.59-1.23) or cerebral palsy (RR = 1.74; 95% CI, 0.97-3.11). Electronic fetal monitoring was associated with reduction in the rate of neonatal seizures by half (RR = 0.50; 95% CI, 0.31-0.80); however, this reduction was not ultimately associated with differences in long-term neonatal neurologic status.9 Researchers have documented a high false-positive rate and inconsistency in provider interpretation of the monitor tracings4 despite efforts to standardize terminology.10 Secondary to these challenges, the use of EFM has contributed to higher rates of cesarean birth (RR = 1.66; 95% CI, 1.30-2.13) and assisted vaginal delivery (RR = 1.16; 95% CI, 1.01-1.32) and has not improved long-term infant or child health outcomes.4 The incidence of cesarean birth in the United States rose to a record high of 32.9% in 2009,11 and results of a recent study found that a nonreassuring FHR tracing is a leading indication for cesarean birth.12 Cesarean birth is associated with greater costs13 and the potential for increased risks associated with surgery, including complications in subsequent pregnancies (uterine rupture and placental implantation problems) and longer hospital stays.14 The National Institutes of Health15,16 and various professional associations have raised concerns regarding the high rate of surgical birth,17,18 and the majority of providers of maternity care in the United States agree that EFM is overused.6–8 The American Congress of Obstetricians and Gynecologists, the American College of Nurse-Midwives (ACNM), and the Association of Women’s Health, Obstetric and Neonatal Nurses have advised against the routine use of EFM for all women. The American Congress of Obstetricians and Gynecologists con136
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cluded, “Despite the frequency of its use, limitations of EFM include poor interobserver and intraobserver reliability, uncertain efficacy, and a high false-positive rate.”7(p193) The ACNM recommended against routine use of EFM for all women and encourages the use of IAFHR for intrapartum FHR surveillance according to clinical guidelines.6 Recognizing that research on the usefulness of EFM was impeded by variability of interpretations of FHR patterns, the National Institute of Child Health and Development organized research planning workshops in 199619 and 200810 to standardize definitions and nomenclature of FHR patterns. Lamaze International concluded that EFM “interfere[s] with women’s ability to actively work with their labors” and must only be used if medically indicated in an effort to promote physiologic approaches to care during labor and birth.20 Similarly, the Association of Women’s Health, Obstetric and Neonatal Nurses acknowledged the limitations of routine use of EFM8 and has published a clinical resource guide that outlines the use of intermittent fetal heart rate monitoring (IFHRM) via auscultation.21 Educational resources and standards for the use of IFHRM have been provided by the Association of Women’s Health, Obstetric and Neonatal Nurses and ACNM for nurses and midwives.6,21 IFHRM is appropriate for women who are at term with a singleton fetus in a cephalic presentation and who enter labor with no obstetric or medical conditions that increase the risk developing fetal acidemia during labor.6 The procedure for IFHRM is provided in Table 1. The timing of listening to fetal heart tones may vary, being conducted during and then after the resolution of a contraction or only after the contraction.6 By listening during a contraction and then for 15 to 30 seconds after, there is a greater potential to detect late decelerations.6 While indications or contraindications for the use of IFHRM may vary on the basis of the maternity care setting and available resources, generally a woman would be considered a candidate if she is at low risk for negative maternal or fetal health outcomes, is not experiencing medical or obstetrical complications, and is in spontaneous labor, without the use of pharmacologic pain relief medications or anesthesia.6,7 The number of women who met this criteria can vary greatly between maternity care settings and may be dependent upon the type of maternity care provider who is overseeing their care,6 but overall the number of women is greater than the current usage rates of almost 90% of women.1 Furthermore, there is potential value in the use of IFHRM, as its use can allow for greater mobility for women in labor.20 While there have been no empirical studies of the clinical and nonclinical factors that have made EFM the standard of maternity care in the United States, one April/June 2014
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Table 1. Technique for performing intermittent auscultationa 1. Perform Leopold maneuvers to identify the fetal presentation and position. 2. Assist the laboring woman into a position that maximizes the provider’s ability to hear the heart rate over the fetal thorax or back while also preserving the woman’s comfort. 3. Assess uterine contractions by palpation. 4. Determine the maternal pulse rate. 5. Place the fetoscope or Doppler ultrasound equipment on the woman’s abdomen, over the fetal thorax or back. 5. Determine the baseline fetal heart rate by listening between contractions. 6. Verify that the maternal pulse differs from the fetal heart rate if necessary. 7. Count the fetal heart rate after a uterine contraction for 30-60 s at regular intervals as outlined by the ACNM, ACOG, or AWHONN standards depending on the stage of labor. 8. Note increases or accelerations or decreases or decelerations from the baseline rate by counting and recording the fetal heart rate using a multiple-count strategy such as counting 3-5 times for 5-15 seconds to note increases or decreases in the counts. Abbreviations: ACOG, American Congress of Obstetricians and Gynecologists; ACNM, American College of Nurse-Midwives; AWHONN, Association of Women’s Health, Obstetric and Neonatal Nurses. a Adapted with permission from American College of Nurse-Midwives.6
popular assumption is that EFM protects against liability.22 It is important to note 2 things about the relationship between EFM and malpractice claims. First, it has not been definitively shown that EFM protects the provider from being sued for malpractice. To the contrary, Lent22 concluded that EFM might actually be a significant contributor to the malpractice crisis in obstetrics. Monitor strips used in EFM are ambiguous proof of nonreassuring fetal status; however, failure to produce a monitor strip recording of the FHR tracing can be construed as failure to meet the standard of care. Second, given that EFM is standard practice and in some sites equipment is built into maternity care units, EFM becomes a quick and simple resource for staff at the bedside. Location of equipment for IAFHR such as a Doppler ultrasound instrument may not be as accessible. Limitations to the application of IAFHR also include the need for higher staffing ratios to carry out the procedure. To use IAFHR, staffing ratios must be 1:1 to allow the nurse to be present at the bedside at frequent intervals of every 15 to 30 minutes during active labor. This staffing ratio is recommended for care of the woman in active labor in a busy labor unit, where ensuring this level of assessment by the nursing staff can be challenging.23 In contrast, EFM offers ongoing information and assessment of fetal well-being when the nurse may not be available. Thus, the use of EFM is perceived as a safety net for the ongoing assessment of fetal well-being despite the busy activities in maternity care units. Providers and educators cite the importance of evidence-based decision making for consumers. Access to maternity care that is “consistent with current scientific evidence about risks and benefits” is a right of childbearing women.24 However, the prevalence of EFM use is not consistent with evidence-based The Journal of Perinatal & Neonatal Nursing
recommendations.25 In the current context of shared decision making between consumers and healthcare providers, the use of EFM must be discussed in terms of the woman’s health status, the evidence regarding IAFHR and EFM, and the woman’s values and beliefs.26 To facilitate informed choice for women during childbirth, access to accurate, publically accessible information is essential to support open discussions between women and their healthcare providers about this topic. Web sites and books can serve as key sources of information for childbearing women. Thirty-three percent of first-time mothers and 12% of experienced mothers reported using books as sources of information on pregnancy and birth.27 The Internet is an even more common source of information, and 97% of mothers reported that they used the Internet for this purpose.1 Nurses and other maternity care providers should be aware of the content of Web sites and books on childbirth to assist women in their care to make informed decisions. We evaluated evidence-based information available to consumers in 3 different types of Web sites: popular maternity sites; maternity provider sites; and childbirth education sites and popular maternity books.
METHODS Web sites Data collection and analysis were conducted between June and August 2013. The Web sites included in the analysis are provided in Table 2. The most popular maternity Web sites were identified by entering the search term “pregnancy” into 4 popular search engines: Google, Yahoo!, Bing, and Ask. Five sites appeared in the top 10 results for all 4 engines, and those were included in the analysis. The traffic ranking of these sites www.jpnnjournal.com
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Table 2. Web sites and the number of Web pages that refer to fetal monitoring
Web sites Popular WebMD BabyCenter Parents What to Expect MedlinePlus Childbirth education organizations Lamaze International HypnoBirthing Alexander Technique International Childbirth Education Association The Bradley Method Professional organizations American Academy of Family Physicians American Congress of Obstetricians and Gynecologists Midwives Alliance of North America American College of Nurse-Midwives Association of Women’s Health Obstetric and Neonatal Nurses Total
No. Web pages mentioning FHR 23 22 11 19 1 13 0 1 0 0 4 30 1 5 8 138
from 12 Web sites. The intended audience for each page was determined: 94 were for pregnant women; 31 were for providers/childbirth educators; and 13 were nonspecific. Because all of the Web pages were publicly available, they all could be used as a source of information for consumers. Therefore, all of them were included in the analysis. Books The books included in the analysis are provided in Table 3. The most popular pregnancy books were identified by their rank on Amazon.com in the category Pregnancy & Childbirth. All books selected were in the top 10 for print and Kindle. Books on conception, nutrition, and breast-feeding and books for fathers/partners were excluded. One book in the top 10 for print, which was not available in Kindle (Natural Childbirth the Bradley Way), and 1 book, which was not a top seller but was affiliated with one of the top childbirth education Web sites (The Official Lamaze Guide), were also included. The final sample included 10 books, all of which had pregnant women as the intended audience. All references to FHR monitoring within each book were identified, transcribed, and imported into NVivo9. Books represented a more unified body than Web sites, which often included many pages
Abbreviation: FHR, fetal heart rate.
Table 3. Books included in the analysis was confirmed using Google Ad Planner28 and Alexa,29 which indicated that each of the 5 sites was ranked in the top 2000 Internet sites; 3 were in the top 500 (BabyCenter, WebMD, and National Institutes of Health). Five additional Web sites from childbirth education organizations that were mentioned in articles on at least 2 of the popular pregnancy Web sites were included. Finally, 5 Web sites of maternity care provider professional organizations were also included in the analysis. References to all types of fetal monitoring were identified by searching each site using the following key terms: fetal monitor(ing), fetal heart, heart monitor(ing), EFM, and FHR (the abbreviation for fetal heart rate monitoring “FHR” was used as a key search term). Then, all relevant sections of the Web site were browsed to capture any pages that did not show up in search results (eg, “pregnancy” but not “toddlers and preschool”). All pages that included a reference to heart rate monitoring during labor were saved in PDF (portable document format) and imported into NVivo 9, a qualitative and mixed-methods analysis program. The following types of content were excluded: personal birth stories; communities/forums; question and answer sections; and videos. Three of the Web sites contained no references to monitoring, which resulted in a sample of 138 pages 138
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What to Expect When You’re Expecting (4th ed.) by Heidi Murkoff and Sharon Mazel, New York, NY: Workman Publishing; 2008 Mayo Clinic Guide to a Health Pregnancy, Roger Harms and Myra Wick, eds., Intercourse, PA: Good Books; 2011 Ina May’s Guide to Childbirth by Ina May Gaskin, New York, NY: Bantam; 2003 Belly Laughs: The Naked Truth About Pregnancy and Childbirth by Jenny McCarthy, Cambridge, MA: Da Capo; 2004 The Girlfriend’s Guide to Pregnancy (2nd ed.) by Vicki Iovine, New York, NY: Pocket Books; 2007 Natural Childbirth the Bradley Way: Revised Edition by Susan McCutcheon, New York, NY: Plume; 1996 HypnoBirthing: The Mongan Method (3rd ed.) by Marie Mongan, Deerfield Beach, FL: Health Communications; 2005 Pregnancy Childbirth and the Newborn: The Complete Guide (4th ed.) by Penny Simpkin, Janet Whalley, Ann Keppler, Janelle Durham, and April Bolding, New York, NY: Meadowbrook Press; 2010 Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation by Pam England and Rob Horowitz, Albuquerque, NM: Partera Press; 1998 The Official Lamaze Guide: Giving Birth With Confidence by Judith Lothian and Charlotte De Vries, New York, NY: Meadowbrook Press; 2005
April/June 2014
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by different authors. Therefore, an additional level of analysis was conducted on the books by comparing each book’s discussion of EFM with that of 2 other interventions with high rates of use (epidurals and induction of labor) to explore how interventions generally were presented in the text. The coverage of each intervention was compared in terms of the number of pages devoted to each and the content of the discussions. Analysis The first author conducted a content analysis and inductive process of open and focused coding as described by Emerson et al.30 In the first round of open coding, statements within were identified that shared exact wording (eg, “limit your mobility”) or had similar meaning (eg, “indicates how baby is doing” and “to assess how he or she is dealing with labor”). These were grouped into different themes (eg, risks/benefits). The themes were developed by the first and last authors. The first author is not a medical professional and offered unbiased review of the content, and the senior author is a medical professional and offered confirmation of medical terminology, confirmation of content analysis themes and codes, and peer review. The final review of themes was conducted within a research team meeting that included both medical and nonmedical professionals. The largest of the themes appeared in at least 10 sources and were designated as core themes. Each core theme was refined into subthemes during a second round of focused coding. During this round of coding, statements were identified within each core theme that shared exact wording or had similar meaning. For example, within the core theme of patient choice, statements were grouped together, indicating women do have a choice (eg, “respectfully decline to use an electronic fetal monitor” and “discuss intermittent fetal monitoring with your caregiver”) or women do not have a choice (eg, “you’ll need continuous EFM” and “you will have a fetal monitor strapped around your belly”).
RESULTS Variations in fetal monitoring terminology Not all sources discussed monitoring in terms that clearly demarcated EFM, continuous EFM, and IAFHR. Some sources used the term “fetal heart rate monitoring” as a general term referring to all forms of monitoring fetal heart tones, and others appeared to use this term to mean only electronic FHR monitoring. For example, the Parents Web site made the ambiguous statement, “Most hospitals will let you pace around, but you’ll need to The Journal of Perinatal & Neonatal Nursing
check fetal heart rate monitoring every 15 minutes.”31 Similarly, many Web sites used the terms “electronic fetal monitoring” or “EFM” without specifying whether this meant continuous monitoring or not. Content on fetal monitoring: Volume and inclusion/exclusion of EFM and IAFHR The core themes that emerged included descriptions of fetal monitoring, admission monitoring, mobility, patient evaluations of monitoring, risks/benefits, and patient choice. Given the increasing relevance of liability in maternity care and its link to the use of EFM, this was also included in the analyses, although it was only mentioned in 4 sources. Core themes and subthemes, volume, and inclusion/exclusion of EFM and IAFHR are provided in Table 4. There was variability in the amount of information provided on EFM and IAFHR in the Web sites and books. Eight Web sites (53%) included at least 1 full Web page dedicated to FHR monitoring, 4 Web sites (27%) only briefly mentioned monitoring, and 3 Web Table 4. Findings for themes and subthemes Web sites, Books, n (%) n (%) Volume of information on monitoring In-depth discussion 8 (53) Brief mention 4 (27) No information 3 (20) Information on IAFHR 8 (67) Descriptions of fetal monitoring How performed 7 (58) Purpose 9 (75) Management of problems 8 (67) Admission monitoring 3 (25) EFM as normative standard 2 (17) EFM and limited mobility 8 (67) Discuss IAFHR 5 (42) Discuss telemetry 6 (50) Patient evaluations of monitoring Positive 1 (8) Negative 5 (42) Both positive and negative 1 (8) Risks and benefits EFM increases risk 8 (67) EFM decreases risk 4 (33) No difference between EFM 5 (42) and IAFHR Patient choice Choice of monitoring 10 (83) No choice of monitoring 9 (75) Liability 2 (17)
5 (50) 5 (50) 0 (0) 6 (60) 7 (70) 8 (80) 3 (30) 8 (80) 5 (60) 6 (60) 6 (60) 6 (60) 1 (10) 6 (60) 1 (10) 7 (70) 1 (10) 4 (40) 6 (60) 6 (60) 2 (20)
Abbreviations: EFM, electronic fetal monitoring; IAFHR, intermittent auscultation of the fetal heart rate.
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sites (20%) included no information on any type of monitoring. Five books (50%) included at least 1 section with an in-depth discussion of monitoring (often 2 pages long), and 5 (50%) mentioned it only briefly. In all, 4 of the 12 Web sites (33%) that included information on monitoring and 4 books (40%) included no specific references to IAFHR. Some of these (Web sites, n = 2; books, n = 1) implied that women can refuse EFM (eg, “whether you want fetal monitoring”32 ) but did not provide information on alternatives. The others treated EFM as the standard of care. For example, Mayo Clinic Guide to a Healthy Pregnancy33 included a detailed description of external and internal EFM but no mention of IAFHR. Descriptions of clinical use of fetal monitoring Descriptions of FHR monitoring were commonly presented within the sources. Seven Web sites (58%) and 7 books (70%) included descriptions of how monitoring is performed. Nine Web sites (75%) and 8 books (80%) described the purpose of FHR monitoring. Most of these (Web sites, n = 7; books, n = 4) only described the purpose in general terms of assessing fetal status: “During labor, your healthcare practitioner and nurse will be checking your baby’s heart rate to keep tabs on how he’s doing and see how he’s tolerating your contractions.”34 However, 3 Web sites and 3 books described how FHR can indicate problems with oxygen levels: “The normal fetal heart rate (FHR) range is between 120 and 160 beats per minute. FHR varies within this range in response to changes in the amount of oxygen that’s available.”35 Some sources also described how problems indicated by monitoring may be managed (Web sites, n = 8; books, n = 3), such as further testing (fetal scalp stimulation or internal monitoring), changing positions, administering oxygen, administering tocolytic medication, or operative delivery. Fetal monitoring during hospital admission Electronic fetal monitoring was commonly represented as a standard of care within discussions of the admission process for a woman in labor. Three Web sites (25%) and 8 books (80%) included descriptions of FHR assessment during admission procedures. With the exception of 2 books, all of these sources presented EFM as the standard method of assessment, although 1 Web site and 1 book critiqued this standard practice. For example, after explaining that many hospitals require admission EFM, Ina May’s Guide to Childbirth36 states, “Giving in to EFM simply because policy requires it may mean that you begin your hospital stay in the most painful and least effective position: lying flat on your 140
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back.” The remaining sources (Web sites, n = 2; books, n = 5) treated admission EFM as the normative standard, similar to The Girlfriend’s Guide to Pregnancy,37 which stated, “In triage, you are examined and put on a monitor.” It is important to note, however, that both of these Web sites and 2 of the 5 books discussed IAFHR in other parts of the source. Mobility In total, 8 Web sites (67%) and 6 books (60%) mentioned that EFM can limit a woman’s mobility. For example, BabyCenter.com34 explained: Electronic fetal monitoring itself isn’t painful. That said, some moms-to-be find it quite uncomfortable to have the transducers strapped to their belly during labor. Being tethered to a monitor can limit your movement and may make it harder for you to cope with contractions, too. (Fetal Monitoring)
However, 3 of the 8 Web sites did not include IAFHR as a way to avoid this limitation. Two of them provided no suggestions for how to avoid limited mobility, and 1 discussed only telemetry. Patient evaluations of fetal monitoring Mixed opinions were identified in discussions of patients’ evaluations of fetal monitoring. One Web site and 1 book stated that some women like EFM and some women do not. However, 5 Web sites (42%) and 6 books (60%) only discussed women’s complaints about EFM, such as feeling physically uncomfortable and anxious, or feeling such as the EFM machine “was drawing the attention of those in the room away from you.”38 At the same time, 1 Web site (8%) and 1 book (10%) described women’s praises of EFM. For example, “My husband helped me visualize the contractions by describing the graph peaks on the monitor. I closed my eyes and imagined myself cycling up a huge mountain, reaching the top, and then coming back down.”31 Risks and benefits One core theme that emerged from the data was discussions of risks and benefits associated with EFM, and there were multiple areas within this theme wherein variation was noted in the presentation of evidence regarding risks and benefits. Several of the sources included general discussions of safety in addition to discussions of specific risks and benefits. Five Web sites (42%) and 4 books (40%) stated that EFM is not safer than IAFHR. Many of these (Web sites, n = 4; books, n = 3) included generalized statements, such as “Remember that routine use of continuous EFM doesn’t make labor safer for your baby” (Continuous EFM).34 April/June 2014
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At the same time, 2 Web sites (17%) and 1 book (10%) made generalized statements about EFM being safer, such as “Cesarean delivery is extremely safe—for both mom and baby—especially with today’s better technology (such as fetal monitors and a variety of other tests) that can more accurately indicate when a fetus is in trouble.”39 Variation between sources on specific risks and benefits were also found. While 4 Web sites (33%) explained that using EFM does not lower the incidence of cerebral palsy, 2 books (20%) stated that babies monitored with EFM, compared with IAFHR, have an increased risk of cerebral palsy. For example, Ina May’s Guide to Childbirth36 states, “In fact, what evidence we have show a slight increase in cerebral palsy among babies who have been electronically monitored.” Finally, while several sources reported that EFM has no impact on infant mortality rates (Web sites, n = 3, 25%; books, n = 4, 40%), 3 Web sites (25%) linked EFM with a lower incidence of death. One of these sources, however, went on to discuss challenges to this finding. Aside from these areas of variation, 8 Web sites (67%) and 7 books (70%) discussed risks of EFM, most of which focused on increased rates of operative delivery (Web sites, n = 6; books, n = 5). There were also Web sites that discussed benefits associated with EFM. For example, 2 Web sites (17%) stated that EFM has been linked to a lower incidence of newborn seizure, but both of these stated the limitations of EFM in reducing long-term problems such as cerebral palsy. Patient choice Another theme within the sources was patient choice. Ten Web sites (83%) and 6 books (60%) presented EFM as something a woman can choose to have, or to not have, during labor. Some of these mentioned discussing EFM with one’s care provider (Web sites, n = 7; books, n = 3) or including IAFHR in a birth plan (Web sites, n = 6; books, n = 3). Sources also provided information on which providers (Web sites, n = 4; books, n = 1) and birth settings (Web sites, n = 2; books, n = 2) are more likely to use EFM or IAFHR and urged women to choose care providers and/or birth settings that would support IAFHR (Web sites, n = 4; books, n = 5). When EFM was not presented as a choice, this was most often within the context of medical conditions or other interventions that require EFM. Eight Web sites (67%) and 4 books (40%) mentioned medical conditions that require EFM, including hypertension, diabetes, fetal distress, intrauterine growth restriction, meconium staining, multiples, prematurity, prolonged labor, sickle cell anemia, and trial of labor after cesarean. Notably, the ACNM18 does not indicate that trial of labor after cesarean requires the use of EFM. Rather, it states The Journal of Perinatal & Neonatal Nursing
that women attempting a trial of labor after cesarean require “heightened surveillance of FHR patterns.” In addition, 7 Web sites (58%) and 4 books (40%) referenced unspecified medical conditions that require EFM. For example, Pregnancy, Childbirth, and the Newborn35 states, “Caregivers generally prefer to use continuous EFM for women with high-risk pregnancies.” Eight Web sites (67%) and 5 books (50%) discussed interventions that require the use of EFM, including epidurals or pain medications, labor induction or augmentation, and the use of magnesium. Liability One final theme identified in the sources was the issue of liability, which appeared in 2 Web sites (17%) and 2 books (20%). The 2 Web sites that discussed liability were provider Web sites. These focused on following standardized protocols and approaches to EFM interpretation and management as a way to avoid liability. For example, ACOG.com40 reports that obstetric providers should use a standardized approach to EFM to avoid liability exposure. The 2 books that discussed the issue of liability were different from the Web sites in that they focused on warning consumers that care providers may use EFM when it is not indicated to protect themselves from a malpractice lawsuit.
DISCUSSION Several themes within these sources of information were found that could limit evidence-based decision making among women regarding FHR monitoring. First, there was a lack of clear terminology when discussing FHR monitoring. There was variation in the amount of information provided, with several sources having no information on IAFHR. Descriptions of the purpose of fetal monitoring were often vague. Discussions of monitoring for hospital admission often treated EFM as the normative standard and, in some cases, did not include IAFHR as an option. In addition, IAFHR was sometimes neglected as an option in discussions of mobility during labor. Information on risks and benefits was often contradictory between sources. Finally, EFM was sometimes erroneously presented as mandatory without reference to potential medical or obstetrical risk factors. The lack of clear terminology when discussing FHR monitoring in these consumer resources may create difficulties in sorting out the implications of each type that may be indicated or appropriate for a woman’s particular birth experience. Similarly, the exclusion of information on IAFHR and the use of EFM as the standard of care within several of the sources clearly limit choice by exclusion of information. More than one-third of the sources included in this study did not mention IAFHR. www.jpnnjournal.com
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The presence of conflicting information and information that is not evidence-based within consumer information is also problematic. Evidence does not support the claims made by several sources that EFM decreases risks.4,5 The term “high risk” is also used as a general phrase without qualification or specificity as a basis for use or nonuse of IFHRM. This is similar to the use of the generalized statement that EFM is not required if one is at “low risk,” which creates difficulty for women who are then left to distinguish high risk from low risk. Many of these sources assume that low risk is a category with clear boundaries, similar to high risk.41 The potential for a woman to move from being a candidate for IFHRM to no longer being a candidate due to a change in risk status is also absent from the discussions. For example, when a woman may change risk status, moving from a lower-risk status such as a woman in spontaneous labor who later becomes “at risk” when she requires augmentation with oxytocin (Pitocin) due to an arrest in progress of active labor, which is an indication for continuous EFM. Given the inconsistent quality of these publicly available sources of information, nurses play a vital role in ensuring that pregnant women are making informed decisions regarding the use of EFM. Pregnant women can receive evidence-based information on monitoring procedures such as EFM and IAFHR as part of the process for preparing their birth plans prenatally. Maternity care nurses are positioned to provide education and information to women during pregnancy and childbirth. Ideally, discussions regarding birth plans, expectations, and desires for the birth experience would occur prenatally between a woman and the primary maternity care provider. Implementation of the birth plan then occurs when the woman enters the maternity care site that has been selected for the birth and is generally directed by the nursing staff. When a laboring woman is unsure of the options or choices, the maternity care nurse can provide evidence-based information regarding the risks and benefits of EFM and IAFHR. For a healthy, low-risk woman in spontaneous labor, the use of IAFHR is the evidence-based approach to care and minimizes disruption to the process of physiologic processes of labor and birth.42 In an effort to support the translation of evidence into practice, hospital systems address issues of staffing to allow for the use of IAFHR when appropriate. It is acknowledged that cost may be a factor in this recommendation. However, if overall quality of care can be enhanced, then overall savings may be recognized. Clear hospital policies are a necessary element of providing optimal fetal assessment during labor. Identification of which women require what level of monitoring and a consistent approach to the frequency and 142
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technique are also necessary. Professional organizations have provided educational resources and materials to aid in this element of ensuring best practice whether IAFHR or EFM is conducted.6,8 Limitations One limitation of this research is that the analysis was limited to a small subsection of all of the available pregnancy Web sites and books. However, this small sample size allowed for a much more in-depth analysis of these sources than could have been conducted on a larger sample. One of the strengths of this study is that it included both Web sites and books in the analysis. While many consumers likely use both sources, it is still necessary to study each, since there are many individuals who do not have Internet access or, conversely, prefer to use Web-based sources as opposed to books. However, these are only 2 of many different sources of consumer information that may be used by pregnant women. Therefore, future research must focus on other sources, such as television, magazines, blogs, or mobile applications. Another limitation of this research is that, while the analysis focused on the content of the sources, it is not known exactly how consumers are incorporating this information into their decision making. Therefore, there is a need for more research on consumers’ use of publicly available information on EFM and IAFHR. Additional research on the impact of liability on EFM use is needed, given that 2 provider Web sites and 2 books connected FHR monitoring to medical malpractice issues.
CONCLUSION Nurses are uniquely positioned to provide both education and implementation of best practices in fetal assessment during labor. A central role nurses can take in addressing the high rates of EFM use is supporting evidence-based shared decision making for women. This includes supporting women’s access to accurate publicly available sources of consumer information. Overall, there is a lack of information on IAFHR in maternity Web sites and books. Some of these sources also present incorrect information or information that is not evidence-based. Therefore, it is important that when possible nurses and other maternity care providers make available accurate, evidence-based information on FHR monitoring to facilitate informed choice and decisions for women during childbirth. References 1. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: New Mothers Speak Out. New York, NY: Childbirth Connection; 2013. April/June 2014
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2. Parer JT, King T, Flanders S, Fox M, Kilpatrick SJ. Fetal acidemia and electronic fetal heart rate patterns: is there evidence of an association? J Matern Fetal Neonatal Med. 2006;19(5):289–294. 3. Parer JT, King T. Fetal heart rate monitoring: is it salvageable? Am J Obstet Gynecol. 2000;182:982–987. 4. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006;19(3):CD006066. 5. Grimes DA, Peipert JF. Electronic fetal monitoring as a public health screening program: the arithmetic of failure. Obstet Gynecol. 2010;116:1397–1400. 6. American College of Nurse-Midwives. Intermittent auscultation for intrapartum fetal heart rate monitoring. J Midwifery Womens Health. 2010;55(4):397–403. 7. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 106. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009; 114(1):192–202. 8. Association of Women’s Health, Obstetric and Neonatal Nurses. Fetal heart monitoring: position statement. https://www.awhonn.org/awhonn/content.do?name=07 PressRoom/07 PositionStatements.htm. Published November 2008. Accessed February 19, 2014. 9. Grant A, O’Brien N, Joy MT, Hennessy E, MacDonald D. Cerebral palsy among children born during the Dublin randomized trials of intrapartum monitoring. Lancet. 1989;2(8674):1233–1236. 10. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs. 2008;37(5):510–515. doi:10.1111/j.1552-6909.2008.00284.x. 11. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2009. Natl Vital Stat Rep. 2010;59(3). http://www.cdc.gov/ nchs/data/nvsr/nvsr59/nvsr59 03.pdf. Accessed February 18, 2014. 12. Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011;118(1):29–38. 13. Allen V, O’Connell C, Farrell S, Baskett T. Economic implications of method of delivery. Am J Obstet Gynecol. 2005;193(1):192–197. 14. MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol. 2008;35(2):293–307. 15. National Institutes of Health. State-of-the-science conference: cesarean delivery on maternal request final panel statement. http://consensus.nih.gov/2006/cesareanstatement.htm. Published March 2006. Accessed February 2, 2014. 16. National Institutes of Health Consensus Development Conference Panel. National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol. 2010;115(6):1279– 1295. 17. American College of Obstetricians and Gynecologists. OB Gyns issue less restrictive VBAC guidelines. http://www. acog.org/About ACOG/News Room/News Releases/2010/ Ob Gyns Issue Less Restrictive VBAC Guidelines. Published July 21, 2010. Accessed February 2, 2014. 18. American College of Nurse-Midwives. Care for women desiring vaginal birth after cesarean. J Midwifery Womens Health. 2011;56(5):517–525. 19. Electronic fetal heart rate monitoring: Research guidelines for interpretation. National Institute of Child Health and Hu-
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man Development Research Planning Workshop. Am J Obstet Gynecol 1997;177(6):1385–1390. Lamaze International. Position paper: Lamaze for the 21st century. http://www.lamazeinternational.org/p/cm/ld/ fid=211. Accessed February 2014. Feinstein N, Sprague A, Trepanier MJ. Fetal Heart Rate Auscultation. 2nd ed. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2009. Lent M. The medical and legal risks of the electronic fetal monitor. Stanford Law Rev. 1999;51(4):807–837. Morrison JC, Chez BF, Davis ID, et al. Intrapartum fetal heart rate assessment: monitoring by auscultation or electronic means. Am J Obstet Gynecol 1993;168: 63–66. Childbirth Connection. The rights of childbearing women. http://www.childbirthconnection.org/article.asp?ck=10084 &ClickedLink=0&26;area=27. Published 2012. Accessed February 19, 2014. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York, NY: Childbirth Connection; 2013. Nieuwenhuijze M, Low LK. Facilitating women’s choice in maternity care. J Clin Ethics. 2013;24(3):276–282. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York, NY: Childbirth Connection; 2006. Google. The 1000 most-visited sites on the Web. Doubleclick ad planner. http://www.google.com/adplanner/static/ top1000. Accessed June 13, 2013. Alexa. Analytics for any Website. http://www.alexa.com. Accessed February 19, 2014. Emerson RM, Fretz RI, Shaw LL. Writing Ethnographic Fieldnotes. Chicago, IL: University of Chicago Press; 1995. Parents. http://www.parents.com. Accessed February 19, 2014. MedlinePlus. http://www.nlm.nih.gov/medlineplus. Accessed February 2, 2014. Harms R, Wick M. Mayo Clinic Guide to a Healthy Pregnancy. Intercourse, PA: Good Books; 2011. BabyCenter. http://www.babycenter.com. Accessed February 2, 2014. Simpkin P, Whalley J, Keppler A, Durham J, Bolding A. Pregnancy, Childbirth, and the Newborn: The Complete Guide. New York, NY: Meadowbrook Press; 2010. Gaskin IM. Ina May’s Guide to Childbirth. New York, NY: Bantam; 2003. Iovine V. The Girlfriend’s Guide to Pregnancy. New York, NY: Pocket Books; 2007. England P, Horowitz R. Birthing From Within: An ExtraOrdinary Guide to Childbirth Preparation. Albuquerque, NM: Partera Press; 1998. Murkoff H, Mazel S. What to Expect When You’re Expecting. New York, NY: Workman Publishing; 2008. American Congress of Obstetricians and Gynecologists. http: //www.acog.org. Accessed February 2, 2014. Institute of Medicine and National Research Council. An Update on Research Issues in the Assessment of Birth Settings: Workshop Summary. Washington, DC: The National Academies Press; 2013. American College of Nurse-Midwives (ACNM), Midwives Alliance of North America (MANA), National Association of Certified Professional Midwives (NACPM). Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. Silver Spring, MD: ACNM, MANA, NACPM; 2012.
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C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins J Perinat Neonat Nurs r Volume 28 Number 2, 135–143 r Copyright
Consumer Information on Fetal Heart Rate Monitoring During Labor: A Content Analysis A Content Analysis Jennifer Torres, PhD; Raymond De Vries, PhD; Lisa Kane Low, PhD, CNM, FACNM ABSTRACT Electronic fetal monitoring (EFM) is used for the majority of births that occur in the United States. While there are indications for use of EFM for women with high-risk pregnancies, its use in low-risk pregnancies is less evidencebased. In low-risk women, the use of EFM is associated with an increased risk for cesarean birth compared with the use of intermittent auscultation of the fetal heart rate. The purpose of this investigation was to evaluate the existence of evidence-based information on fetal heart rate monitoring in popular consumer-focused maternity books and Web sites. Content analysis of information in consumeroriented Web sites and books was completed using the NVivo software (QRSinternational, Melbourne, Australia). Themes identified included lack of clear terminology when discussing fetal monitoring, use of broad categories such as low risk and high risk, limited presentation of information about intermittent auscultation, and presentation of Author Affiliations: Department of Sociology (Dr Torres), Center for Bioethics, Department of Graduate Medical Education, School of Medicine (Dr De Vries), and School of Nursing; and Department of Women’s Studies (Dr Low), University of Michigan, Ann Arbor. Funding for this project was received from the Institute for Research on Women and Gender and the CUBE program, University of Michigan. The authors thank the members of the University of Michigan CUBE funded project: Examination of the clinical and non-clinical factors influencing use of electronic fetal monitoring, Sonya Dal Cin, Scott Greer, and Denise Lillvis. Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Lisa Kane Low, PhD, CNM, FACNM, School of Nursing and Department of Women’s Studies, University of Michigan, 400 N Ingalls, Ste 3320, Ann Arbor, MI 48109 ([email protected]). Submitted for publication: January 9, 2014; accepted for publication: February 26, 2014. The Journal of Perinatal & Neonatal Nursing
EFM as the standard of care, particularly upon admission into the labor unit. More than one-third of the sources did not mention auscultation, and conflicting information about monitoring methods was presented. The availability of accurate, publically accessible information offers consumers the opportunity to translate knowledge into the power to seek evidence-based care practices during their maternity care experience. Key Words: consumer publications, electronic fetal monitoring, evidence-based practice, intermittent auscultation
urrently, in the United States, the predominant method of fetal assessment during labor is the use of electronic fetal monitoring (EFM).1 When EFM was introduced in the 1960s, anticipated improvements in neonatal outcomes and reduction of fetal acidemia were assumed.2,3 Instead, the use of continuous EFM has not been shown to improve perinatal outcomes compared with intermittent auscultation of the fetal heart rate (IAFHR) when used in low-risk women.4,5 Furthermore, there is evidence that the overuse of EFM for low-risk women increases the incidence of cesarean birth when compared with IAFHR.5 In recognition of the limited evidence to support generalized use of EFM for all women, guidelines from professional organizations indicate that IAFHR is as safe as EFM as a method of assessing fetal well-being in women who are at term and have no other obstetric or medical risk factors that increase the risk for fetal acidemia during labor.6–8 Given this conclusion, it is unclear why EFM continues to be used for most women experiencing a lowrisk pregnancy and birth. There are a number of factors that contribute to the use of EFM as the dominate
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method. Women can access information about fetal assessment during labor, and the use of IAFHR and EFM is often reviewed in childbirth education classes so that they can make informed choices about fetal assessment during labor. However, it is possible that women are knowledgeable about IAFHR as an evidence-based intervention that may promote normal birth and reduce the risk for interventions such as cesarean birth. Therefore, the purpose of this article was to evaluate the availability and quality of consumer information on EFM within 2 publicly available sources: maternity Web sites and consumer-oriented books.
BACKGROUND Listening to Mothers III, a survey of women in the United States who gave birth in 2011-2012, indicated that 89% of women were monitored with continuous EFM.1 However, when compared with IAFHR, EFM does not reduce the overall risk of perinatal death (relative risk [RR] = 0.85; 95%; confidence interval [CI], 0.59-1.23) or cerebral palsy (RR = 1.74; 95% CI, 0.97-3.11). Electronic fetal monitoring was associated with reduction in the rate of neonatal seizures by half (RR = 0.50; 95% CI, 0.31-0.80); however, this reduction was not ultimately associated with differences in long-term neonatal neurologic status.9 Researchers have documented a high false-positive rate and inconsistency in provider interpretation of the monitor tracings4 despite efforts to standardize terminology.10 Secondary to these challenges, the use of EFM has contributed to higher rates of cesarean birth (RR = 1.66; 95% CI, 1.30-2.13) and assisted vaginal delivery (RR = 1.16; 95% CI, 1.01-1.32) and has not improved long-term infant or child health outcomes.4 The incidence of cesarean birth in the United States rose to a record high of 32.9% in 2009,11 and results of a recent study found that a nonreassuring FHR tracing is a leading indication for cesarean birth.12 Cesarean birth is associated with greater costs13 and the potential for increased risks associated with surgery, including complications in subsequent pregnancies (uterine rupture and placental implantation problems) and longer hospital stays.14 The National Institutes of Health15,16 and various professional associations have raised concerns regarding the high rate of surgical birth,17,18 and the majority of providers of maternity care in the United States agree that EFM is overused.6–8 The American Congress of Obstetricians and Gynecologists, the American College of Nurse-Midwives (ACNM), and the Association of Women’s Health, Obstetric and Neonatal Nurses have advised against the routine use of EFM for all women. The American Congress of Obstetricians and Gynecologists con136
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cluded, “Despite the frequency of its use, limitations of EFM include poor interobserver and intraobserver reliability, uncertain efficacy, and a high false-positive rate.”7(p193) The ACNM recommended against routine use of EFM for all women and encourages the use of IAFHR for intrapartum FHR surveillance according to clinical guidelines.6 Recognizing that research on the usefulness of EFM was impeded by variability of interpretations of FHR patterns, the National Institute of Child Health and Development organized research planning workshops in 199619 and 200810 to standardize definitions and nomenclature of FHR patterns. Lamaze International concluded that EFM “interfere[s] with women’s ability to actively work with their labors” and must only be used if medically indicated in an effort to promote physiologic approaches to care during labor and birth.20 Similarly, the Association of Women’s Health, Obstetric and Neonatal Nurses acknowledged the limitations of routine use of EFM8 and has published a clinical resource guide that outlines the use of intermittent fetal heart rate monitoring (IFHRM) via auscultation.21 Educational resources and standards for the use of IFHRM have been provided by the Association of Women’s Health, Obstetric and Neonatal Nurses and ACNM for nurses and midwives.6,21 IFHRM is appropriate for women who are at term with a singleton fetus in a cephalic presentation and who enter labor with no obstetric or medical conditions that increase the risk developing fetal acidemia during labor.6 The procedure for IFHRM is provided in Table 1. The timing of listening to fetal heart tones may vary, being conducted during and then after the resolution of a contraction or only after the contraction.6 By listening during a contraction and then for 15 to 30 seconds after, there is a greater potential to detect late decelerations.6 While indications or contraindications for the use of IFHRM may vary on the basis of the maternity care setting and available resources, generally a woman would be considered a candidate if she is at low risk for negative maternal or fetal health outcomes, is not experiencing medical or obstetrical complications, and is in spontaneous labor, without the use of pharmacologic pain relief medications or anesthesia.6,7 The number of women who met this criteria can vary greatly between maternity care settings and may be dependent upon the type of maternity care provider who is overseeing their care,6 but overall the number of women is greater than the current usage rates of almost 90% of women.1 Furthermore, there is potential value in the use of IFHRM, as its use can allow for greater mobility for women in labor.20 While there have been no empirical studies of the clinical and nonclinical factors that have made EFM the standard of maternity care in the United States, one April/June 2014
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Table 1. Technique for performing intermittent auscultationa 1. Perform Leopold maneuvers to identify the fetal presentation and position. 2. Assist the laboring woman into a position that maximizes the provider’s ability to hear the heart rate over the fetal thorax or back while also preserving the woman’s comfort. 3. Assess uterine contractions by palpation. 4. Determine the maternal pulse rate. 5. Place the fetoscope or Doppler ultrasound equipment on the woman’s abdomen, over the fetal thorax or back. 5. Determine the baseline fetal heart rate by listening between contractions. 6. Verify that the maternal pulse differs from the fetal heart rate if necessary. 7. Count the fetal heart rate after a uterine contraction for 30-60 s at regular intervals as outlined by the ACNM, ACOG, or AWHONN standards depending on the stage of labor. 8. Note increases or accelerations or decreases or decelerations from the baseline rate by counting and recording the fetal heart rate using a multiple-count strategy such as counting 3-5 times for 5-15 seconds to note increases or decreases in the counts. Abbreviations: ACOG, American Congress of Obstetricians and Gynecologists; ACNM, American College of Nurse-Midwives; AWHONN, Association of Women’s Health, Obstetric and Neonatal Nurses. a Adapted with permission from American College of Nurse-Midwives.6
popular assumption is that EFM protects against liability.22 It is important to note 2 things about the relationship between EFM and malpractice claims. First, it has not been definitively shown that EFM protects the provider from being sued for malpractice. To the contrary, Lent22 concluded that EFM might actually be a significant contributor to the malpractice crisis in obstetrics. Monitor strips used in EFM are ambiguous proof of nonreassuring fetal status; however, failure to produce a monitor strip recording of the FHR tracing can be construed as failure to meet the standard of care. Second, given that EFM is standard practice and in some sites equipment is built into maternity care units, EFM becomes a quick and simple resource for staff at the bedside. Location of equipment for IAFHR such as a Doppler ultrasound instrument may not be as accessible. Limitations to the application of IAFHR also include the need for higher staffing ratios to carry out the procedure. To use IAFHR, staffing ratios must be 1:1 to allow the nurse to be present at the bedside at frequent intervals of every 15 to 30 minutes during active labor. This staffing ratio is recommended for care of the woman in active labor in a busy labor unit, where ensuring this level of assessment by the nursing staff can be challenging.23 In contrast, EFM offers ongoing information and assessment of fetal well-being when the nurse may not be available. Thus, the use of EFM is perceived as a safety net for the ongoing assessment of fetal well-being despite the busy activities in maternity care units. Providers and educators cite the importance of evidence-based decision making for consumers. Access to maternity care that is “consistent with current scientific evidence about risks and benefits” is a right of childbearing women.24 However, the prevalence of EFM use is not consistent with evidence-based The Journal of Perinatal & Neonatal Nursing
recommendations.25 In the current context of shared decision making between consumers and healthcare providers, the use of EFM must be discussed in terms of the woman’s health status, the evidence regarding IAFHR and EFM, and the woman’s values and beliefs.26 To facilitate informed choice for women during childbirth, access to accurate, publically accessible information is essential to support open discussions between women and their healthcare providers about this topic. Web sites and books can serve as key sources of information for childbearing women. Thirty-three percent of first-time mothers and 12% of experienced mothers reported using books as sources of information on pregnancy and birth.27 The Internet is an even more common source of information, and 97% of mothers reported that they used the Internet for this purpose.1 Nurses and other maternity care providers should be aware of the content of Web sites and books on childbirth to assist women in their care to make informed decisions. We evaluated evidence-based information available to consumers in 3 different types of Web sites: popular maternity sites; maternity provider sites; and childbirth education sites and popular maternity books.
METHODS Web sites Data collection and analysis were conducted between June and August 2013. The Web sites included in the analysis are provided in Table 2. The most popular maternity Web sites were identified by entering the search term “pregnancy” into 4 popular search engines: Google, Yahoo!, Bing, and Ask. Five sites appeared in the top 10 results for all 4 engines, and those were included in the analysis. The traffic ranking of these sites www.jpnnjournal.com
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Table 2. Web sites and the number of Web pages that refer to fetal monitoring
Web sites Popular WebMD BabyCenter Parents What to Expect MedlinePlus Childbirth education organizations Lamaze International HypnoBirthing Alexander Technique International Childbirth Education Association The Bradley Method Professional organizations American Academy of Family Physicians American Congress of Obstetricians and Gynecologists Midwives Alliance of North America American College of Nurse-Midwives Association of Women’s Health Obstetric and Neonatal Nurses Total
No. Web pages mentioning FHR 23 22 11 19 1 13 0 1 0 0 4 30 1 5 8 138
from 12 Web sites. The intended audience for each page was determined: 94 were for pregnant women; 31 were for providers/childbirth educators; and 13 were nonspecific. Because all of the Web pages were publicly available, they all could be used as a source of information for consumers. Therefore, all of them were included in the analysis. Books The books included in the analysis are provided in Table 3. The most popular pregnancy books were identified by their rank on Amazon.com in the category Pregnancy & Childbirth. All books selected were in the top 10 for print and Kindle. Books on conception, nutrition, and breast-feeding and books for fathers/partners were excluded. One book in the top 10 for print, which was not available in Kindle (Natural Childbirth the Bradley Way), and 1 book, which was not a top seller but was affiliated with one of the top childbirth education Web sites (The Official Lamaze Guide), were also included. The final sample included 10 books, all of which had pregnant women as the intended audience. All references to FHR monitoring within each book were identified, transcribed, and imported into NVivo9. Books represented a more unified body than Web sites, which often included many pages
Abbreviation: FHR, fetal heart rate.
Table 3. Books included in the analysis was confirmed using Google Ad Planner28 and Alexa,29 which indicated that each of the 5 sites was ranked in the top 2000 Internet sites; 3 were in the top 500 (BabyCenter, WebMD, and National Institutes of Health). Five additional Web sites from childbirth education organizations that were mentioned in articles on at least 2 of the popular pregnancy Web sites were included. Finally, 5 Web sites of maternity care provider professional organizations were also included in the analysis. References to all types of fetal monitoring were identified by searching each site using the following key terms: fetal monitor(ing), fetal heart, heart monitor(ing), EFM, and FHR (the abbreviation for fetal heart rate monitoring “FHR” was used as a key search term). Then, all relevant sections of the Web site were browsed to capture any pages that did not show up in search results (eg, “pregnancy” but not “toddlers and preschool”). All pages that included a reference to heart rate monitoring during labor were saved in PDF (portable document format) and imported into NVivo 9, a qualitative and mixed-methods analysis program. The following types of content were excluded: personal birth stories; communities/forums; question and answer sections; and videos. Three of the Web sites contained no references to monitoring, which resulted in a sample of 138 pages 138
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What to Expect When You’re Expecting (4th ed.) by Heidi Murkoff and Sharon Mazel, New York, NY: Workman Publishing; 2008 Mayo Clinic Guide to a Health Pregnancy, Roger Harms and Myra Wick, eds., Intercourse, PA: Good Books; 2011 Ina May’s Guide to Childbirth by Ina May Gaskin, New York, NY: Bantam; 2003 Belly Laughs: The Naked Truth About Pregnancy and Childbirth by Jenny McCarthy, Cambridge, MA: Da Capo; 2004 The Girlfriend’s Guide to Pregnancy (2nd ed.) by Vicki Iovine, New York, NY: Pocket Books; 2007 Natural Childbirth the Bradley Way: Revised Edition by Susan McCutcheon, New York, NY: Plume; 1996 HypnoBirthing: The Mongan Method (3rd ed.) by Marie Mongan, Deerfield Beach, FL: Health Communications; 2005 Pregnancy Childbirth and the Newborn: The Complete Guide (4th ed.) by Penny Simpkin, Janet Whalley, Ann Keppler, Janelle Durham, and April Bolding, New York, NY: Meadowbrook Press; 2010 Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation by Pam England and Rob Horowitz, Albuquerque, NM: Partera Press; 1998 The Official Lamaze Guide: Giving Birth With Confidence by Judith Lothian and Charlotte De Vries, New York, NY: Meadowbrook Press; 2005
April/June 2014
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by different authors. Therefore, an additional level of analysis was conducted on the books by comparing each book’s discussion of EFM with that of 2 other interventions with high rates of use (epidurals and induction of labor) to explore how interventions generally were presented in the text. The coverage of each intervention was compared in terms of the number of pages devoted to each and the content of the discussions. Analysis The first author conducted a content analysis and inductive process of open and focused coding as described by Emerson et al.30 In the first round of open coding, statements within were identified that shared exact wording (eg, “limit your mobility”) or had similar meaning (eg, “indicates how baby is doing” and “to assess how he or she is dealing with labor”). These were grouped into different themes (eg, risks/benefits). The themes were developed by the first and last authors. The first author is not a medical professional and offered unbiased review of the content, and the senior author is a medical professional and offered confirmation of medical terminology, confirmation of content analysis themes and codes, and peer review. The final review of themes was conducted within a research team meeting that included both medical and nonmedical professionals. The largest of the themes appeared in at least 10 sources and were designated as core themes. Each core theme was refined into subthemes during a second round of focused coding. During this round of coding, statements were identified within each core theme that shared exact wording or had similar meaning. For example, within the core theme of patient choice, statements were grouped together, indicating women do have a choice (eg, “respectfully decline to use an electronic fetal monitor” and “discuss intermittent fetal monitoring with your caregiver”) or women do not have a choice (eg, “you’ll need continuous EFM” and “you will have a fetal monitor strapped around your belly”).
RESULTS Variations in fetal monitoring terminology Not all sources discussed monitoring in terms that clearly demarcated EFM, continuous EFM, and IAFHR. Some sources used the term “fetal heart rate monitoring” as a general term referring to all forms of monitoring fetal heart tones, and others appeared to use this term to mean only electronic FHR monitoring. For example, the Parents Web site made the ambiguous statement, “Most hospitals will let you pace around, but you’ll need to The Journal of Perinatal & Neonatal Nursing
check fetal heart rate monitoring every 15 minutes.”31 Similarly, many Web sites used the terms “electronic fetal monitoring” or “EFM” without specifying whether this meant continuous monitoring or not. Content on fetal monitoring: Volume and inclusion/exclusion of EFM and IAFHR The core themes that emerged included descriptions of fetal monitoring, admission monitoring, mobility, patient evaluations of monitoring, risks/benefits, and patient choice. Given the increasing relevance of liability in maternity care and its link to the use of EFM, this was also included in the analyses, although it was only mentioned in 4 sources. Core themes and subthemes, volume, and inclusion/exclusion of EFM and IAFHR are provided in Table 4. There was variability in the amount of information provided on EFM and IAFHR in the Web sites and books. Eight Web sites (53%) included at least 1 full Web page dedicated to FHR monitoring, 4 Web sites (27%) only briefly mentioned monitoring, and 3 Web Table 4. Findings for themes and subthemes Web sites, Books, n (%) n (%) Volume of information on monitoring In-depth discussion 8 (53) Brief mention 4 (27) No information 3 (20) Information on IAFHR 8 (67) Descriptions of fetal monitoring How performed 7 (58) Purpose 9 (75) Management of problems 8 (67) Admission monitoring 3 (25) EFM as normative standard 2 (17) EFM and limited mobility 8 (67) Discuss IAFHR 5 (42) Discuss telemetry 6 (50) Patient evaluations of monitoring Positive 1 (8) Negative 5 (42) Both positive and negative 1 (8) Risks and benefits EFM increases risk 8 (67) EFM decreases risk 4 (33) No difference between EFM 5 (42) and IAFHR Patient choice Choice of monitoring 10 (83) No choice of monitoring 9 (75) Liability 2 (17)
5 (50) 5 (50) 0 (0) 6 (60) 7 (70) 8 (80) 3 (30) 8 (80) 5 (60) 6 (60) 6 (60) 6 (60) 1 (10) 6 (60) 1 (10) 7 (70) 1 (10) 4 (40) 6 (60) 6 (60) 2 (20)
Abbreviations: EFM, electronic fetal monitoring; IAFHR, intermittent auscultation of the fetal heart rate.
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sites (20%) included no information on any type of monitoring. Five books (50%) included at least 1 section with an in-depth discussion of monitoring (often 2 pages long), and 5 (50%) mentioned it only briefly. In all, 4 of the 12 Web sites (33%) that included information on monitoring and 4 books (40%) included no specific references to IAFHR. Some of these (Web sites, n = 2; books, n = 1) implied that women can refuse EFM (eg, “whether you want fetal monitoring”32 ) but did not provide information on alternatives. The others treated EFM as the standard of care. For example, Mayo Clinic Guide to a Healthy Pregnancy33 included a detailed description of external and internal EFM but no mention of IAFHR. Descriptions of clinical use of fetal monitoring Descriptions of FHR monitoring were commonly presented within the sources. Seven Web sites (58%) and 7 books (70%) included descriptions of how monitoring is performed. Nine Web sites (75%) and 8 books (80%) described the purpose of FHR monitoring. Most of these (Web sites, n = 7; books, n = 4) only described the purpose in general terms of assessing fetal status: “During labor, your healthcare practitioner and nurse will be checking your baby’s heart rate to keep tabs on how he’s doing and see how he’s tolerating your contractions.”34 However, 3 Web sites and 3 books described how FHR can indicate problems with oxygen levels: “The normal fetal heart rate (FHR) range is between 120 and 160 beats per minute. FHR varies within this range in response to changes in the amount of oxygen that’s available.”35 Some sources also described how problems indicated by monitoring may be managed (Web sites, n = 8; books, n = 3), such as further testing (fetal scalp stimulation or internal monitoring), changing positions, administering oxygen, administering tocolytic medication, or operative delivery. Fetal monitoring during hospital admission Electronic fetal monitoring was commonly represented as a standard of care within discussions of the admission process for a woman in labor. Three Web sites (25%) and 8 books (80%) included descriptions of FHR assessment during admission procedures. With the exception of 2 books, all of these sources presented EFM as the standard method of assessment, although 1 Web site and 1 book critiqued this standard practice. For example, after explaining that many hospitals require admission EFM, Ina May’s Guide to Childbirth36 states, “Giving in to EFM simply because policy requires it may mean that you begin your hospital stay in the most painful and least effective position: lying flat on your 140
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back.” The remaining sources (Web sites, n = 2; books, n = 5) treated admission EFM as the normative standard, similar to The Girlfriend’s Guide to Pregnancy,37 which stated, “In triage, you are examined and put on a monitor.” It is important to note, however, that both of these Web sites and 2 of the 5 books discussed IAFHR in other parts of the source. Mobility In total, 8 Web sites (67%) and 6 books (60%) mentioned that EFM can limit a woman’s mobility. For example, BabyCenter.com34 explained: Electronic fetal monitoring itself isn’t painful. That said, some moms-to-be find it quite uncomfortable to have the transducers strapped to their belly during labor. Being tethered to a monitor can limit your movement and may make it harder for you to cope with contractions, too. (Fetal Monitoring)
However, 3 of the 8 Web sites did not include IAFHR as a way to avoid this limitation. Two of them provided no suggestions for how to avoid limited mobility, and 1 discussed only telemetry. Patient evaluations of fetal monitoring Mixed opinions were identified in discussions of patients’ evaluations of fetal monitoring. One Web site and 1 book stated that some women like EFM and some women do not. However, 5 Web sites (42%) and 6 books (60%) only discussed women’s complaints about EFM, such as feeling physically uncomfortable and anxious, or feeling such as the EFM machine “was drawing the attention of those in the room away from you.”38 At the same time, 1 Web site (8%) and 1 book (10%) described women’s praises of EFM. For example, “My husband helped me visualize the contractions by describing the graph peaks on the monitor. I closed my eyes and imagined myself cycling up a huge mountain, reaching the top, and then coming back down.”31 Risks and benefits One core theme that emerged from the data was discussions of risks and benefits associated with EFM, and there were multiple areas within this theme wherein variation was noted in the presentation of evidence regarding risks and benefits. Several of the sources included general discussions of safety in addition to discussions of specific risks and benefits. Five Web sites (42%) and 4 books (40%) stated that EFM is not safer than IAFHR. Many of these (Web sites, n = 4; books, n = 3) included generalized statements, such as “Remember that routine use of continuous EFM doesn’t make labor safer for your baby” (Continuous EFM).34 April/June 2014
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At the same time, 2 Web sites (17%) and 1 book (10%) made generalized statements about EFM being safer, such as “Cesarean delivery is extremely safe—for both mom and baby—especially with today’s better technology (such as fetal monitors and a variety of other tests) that can more accurately indicate when a fetus is in trouble.”39 Variation between sources on specific risks and benefits were also found. While 4 Web sites (33%) explained that using EFM does not lower the incidence of cerebral palsy, 2 books (20%) stated that babies monitored with EFM, compared with IAFHR, have an increased risk of cerebral palsy. For example, Ina May’s Guide to Childbirth36 states, “In fact, what evidence we have show a slight increase in cerebral palsy among babies who have been electronically monitored.” Finally, while several sources reported that EFM has no impact on infant mortality rates (Web sites, n = 3, 25%; books, n = 4, 40%), 3 Web sites (25%) linked EFM with a lower incidence of death. One of these sources, however, went on to discuss challenges to this finding. Aside from these areas of variation, 8 Web sites (67%) and 7 books (70%) discussed risks of EFM, most of which focused on increased rates of operative delivery (Web sites, n = 6; books, n = 5). There were also Web sites that discussed benefits associated with EFM. For example, 2 Web sites (17%) stated that EFM has been linked to a lower incidence of newborn seizure, but both of these stated the limitations of EFM in reducing long-term problems such as cerebral palsy. Patient choice Another theme within the sources was patient choice. Ten Web sites (83%) and 6 books (60%) presented EFM as something a woman can choose to have, or to not have, during labor. Some of these mentioned discussing EFM with one’s care provider (Web sites, n = 7; books, n = 3) or including IAFHR in a birth plan (Web sites, n = 6; books, n = 3). Sources also provided information on which providers (Web sites, n = 4; books, n = 1) and birth settings (Web sites, n = 2; books, n = 2) are more likely to use EFM or IAFHR and urged women to choose care providers and/or birth settings that would support IAFHR (Web sites, n = 4; books, n = 5). When EFM was not presented as a choice, this was most often within the context of medical conditions or other interventions that require EFM. Eight Web sites (67%) and 4 books (40%) mentioned medical conditions that require EFM, including hypertension, diabetes, fetal distress, intrauterine growth restriction, meconium staining, multiples, prematurity, prolonged labor, sickle cell anemia, and trial of labor after cesarean. Notably, the ACNM18 does not indicate that trial of labor after cesarean requires the use of EFM. Rather, it states The Journal of Perinatal & Neonatal Nursing
that women attempting a trial of labor after cesarean require “heightened surveillance of FHR patterns.” In addition, 7 Web sites (58%) and 4 books (40%) referenced unspecified medical conditions that require EFM. For example, Pregnancy, Childbirth, and the Newborn35 states, “Caregivers generally prefer to use continuous EFM for women with high-risk pregnancies.” Eight Web sites (67%) and 5 books (50%) discussed interventions that require the use of EFM, including epidurals or pain medications, labor induction or augmentation, and the use of magnesium. Liability One final theme identified in the sources was the issue of liability, which appeared in 2 Web sites (17%) and 2 books (20%). The 2 Web sites that discussed liability were provider Web sites. These focused on following standardized protocols and approaches to EFM interpretation and management as a way to avoid liability. For example, ACOG.com40 reports that obstetric providers should use a standardized approach to EFM to avoid liability exposure. The 2 books that discussed the issue of liability were different from the Web sites in that they focused on warning consumers that care providers may use EFM when it is not indicated to protect themselves from a malpractice lawsuit.
DISCUSSION Several themes within these sources of information were found that could limit evidence-based decision making among women regarding FHR monitoring. First, there was a lack of clear terminology when discussing FHR monitoring. There was variation in the amount of information provided, with several sources having no information on IAFHR. Descriptions of the purpose of fetal monitoring were often vague. Discussions of monitoring for hospital admission often treated EFM as the normative standard and, in some cases, did not include IAFHR as an option. In addition, IAFHR was sometimes neglected as an option in discussions of mobility during labor. Information on risks and benefits was often contradictory between sources. Finally, EFM was sometimes erroneously presented as mandatory without reference to potential medical or obstetrical risk factors. The lack of clear terminology when discussing FHR monitoring in these consumer resources may create difficulties in sorting out the implications of each type that may be indicated or appropriate for a woman’s particular birth experience. Similarly, the exclusion of information on IAFHR and the use of EFM as the standard of care within several of the sources clearly limit choice by exclusion of information. More than one-third of the sources included in this study did not mention IAFHR. www.jpnnjournal.com
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The presence of conflicting information and information that is not evidence-based within consumer information is also problematic. Evidence does not support the claims made by several sources that EFM decreases risks.4,5 The term “high risk” is also used as a general phrase without qualification or specificity as a basis for use or nonuse of IFHRM. This is similar to the use of the generalized statement that EFM is not required if one is at “low risk,” which creates difficulty for women who are then left to distinguish high risk from low risk. Many of these sources assume that low risk is a category with clear boundaries, similar to high risk.41 The potential for a woman to move from being a candidate for IFHRM to no longer being a candidate due to a change in risk status is also absent from the discussions. For example, when a woman may change risk status, moving from a lower-risk status such as a woman in spontaneous labor who later becomes “at risk” when she requires augmentation with oxytocin (Pitocin) due to an arrest in progress of active labor, which is an indication for continuous EFM. Given the inconsistent quality of these publicly available sources of information, nurses play a vital role in ensuring that pregnant women are making informed decisions regarding the use of EFM. Pregnant women can receive evidence-based information on monitoring procedures such as EFM and IAFHR as part of the process for preparing their birth plans prenatally. Maternity care nurses are positioned to provide education and information to women during pregnancy and childbirth. Ideally, discussions regarding birth plans, expectations, and desires for the birth experience would occur prenatally between a woman and the primary maternity care provider. Implementation of the birth plan then occurs when the woman enters the maternity care site that has been selected for the birth and is generally directed by the nursing staff. When a laboring woman is unsure of the options or choices, the maternity care nurse can provide evidence-based information regarding the risks and benefits of EFM and IAFHR. For a healthy, low-risk woman in spontaneous labor, the use of IAFHR is the evidence-based approach to care and minimizes disruption to the process of physiologic processes of labor and birth.42 In an effort to support the translation of evidence into practice, hospital systems address issues of staffing to allow for the use of IAFHR when appropriate. It is acknowledged that cost may be a factor in this recommendation. However, if overall quality of care can be enhanced, then overall savings may be recognized. Clear hospital policies are a necessary element of providing optimal fetal assessment during labor. Identification of which women require what level of monitoring and a consistent approach to the frequency and 142
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technique are also necessary. Professional organizations have provided educational resources and materials to aid in this element of ensuring best practice whether IAFHR or EFM is conducted.6,8 Limitations One limitation of this research is that the analysis was limited to a small subsection of all of the available pregnancy Web sites and books. However, this small sample size allowed for a much more in-depth analysis of these sources than could have been conducted on a larger sample. One of the strengths of this study is that it included both Web sites and books in the analysis. While many consumers likely use both sources, it is still necessary to study each, since there are many individuals who do not have Internet access or, conversely, prefer to use Web-based sources as opposed to books. However, these are only 2 of many different sources of consumer information that may be used by pregnant women. Therefore, future research must focus on other sources, such as television, magazines, blogs, or mobile applications. Another limitation of this research is that, while the analysis focused on the content of the sources, it is not known exactly how consumers are incorporating this information into their decision making. Therefore, there is a need for more research on consumers’ use of publicly available information on EFM and IAFHR. Additional research on the impact of liability on EFM use is needed, given that 2 provider Web sites and 2 books connected FHR monitoring to medical malpractice issues.
CONCLUSION Nurses are uniquely positioned to provide both education and implementation of best practices in fetal assessment during labor. A central role nurses can take in addressing the high rates of EFM use is supporting evidence-based shared decision making for women. This includes supporting women’s access to accurate publicly available sources of consumer information. Overall, there is a lack of information on IAFHR in maternity Web sites and books. Some of these sources also present incorrect information or information that is not evidence-based. Therefore, it is important that when possible nurses and other maternity care providers make available accurate, evidence-based information on FHR monitoring to facilitate informed choice and decisions for women during childbirth. References 1. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: New Mothers Speak Out. New York, NY: Childbirth Connection; 2013. April/June 2014
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