Does Electronic Fetal Monitoring Increase the Rate of Unnecessary Cesareans?
Or perhaps the bigger question is whether Dr. Alex Friedman should prepare for an angry backlash for criticizing such precious tenets?
Dr. Friedman was interviewed for the June 7 Associated Press article, Overtreated: More medical care isn’t always better.
There are numerous reasons that one of three U.S. births now is by cesarean, but Dr. Alex Friedman blames some on an imprecise monitor strapped to laboring women. Too often, he has sliced open a mother’s abdomen fearing the worst, only to pull out a pink, screaming bundle.
“Everyone knows it’s a bad test,” said Friedman of the Hospital of the University of Pennsylvania. “You haven’t done the patient a big service by doing an unnecessary surgery.”
Electronic fetal monitors record changes in the baby’s heart rate, a possible sign of too little oxygen. They became a tradition — now used in 85 percent of births — years before research could prove how well they work.
Guidelines issued last summer, aiming to help doctors better interpret which tests are worrisome, acknowledge the monitors haven’t reduced deaths or cerebral palsy. But they do increase the chances of a C-section. While they should be used in high-risk women, the guidelines say the low-risk could fare as well if a nurse regularly checked the baby’s heart rate.
Later this year, the National Institutes of Health will begin a major study to see if adding a newer technology — a type of fetal EKG already used in Europe — to the heart-rate monitor would better identify which babies really are struggling and need rapid delivery.
On May 31, Dr. Friedman wrote an op-ed piece for the Philadephia Inquirer entitled, “Dangerous delivery shows peril of multiple C-sections”
The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.
More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.
At the same time, it’s becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.
Repeat C-sections pose more risk than a first section for many reasons. One factor concerns anatomy. When a doctor performs a first cesarean, the layers of tissue look and feel very different from each other. These visual cues and textures guide the surgeon, indicating exactly where to cut.
The surgery is simple: the surgeon cuts, spreads, and pokes, layer by layer, until reaching the baby. The surgeon first opens the skin a few centimeters above the pubic bone. The fat underneath easily gives way until the connecting fascia is reached. The tough, fibrous fascia, which holds the intestines in the abdomen, is cut at the midline and opened in either direction. The beefy abdominal muscles beneath are spread.
Finally, the glossy peritoneum, the last layer of the abdomen, is entered, and only the uterus lies between the doctor and the baby. In a term patient, the maroon, swollen uterus, flanked by finger-size veins, fills almost the whole abdomen, pushing the intestines up. The surgeon moves the bladder out of the way, cuts the lower uterus open, and is met by a baby’s foot, face, elbow, or behind, depending on how the baby is positioned.
The surgeon loses the advantage of good anatomy after the first section. The tissue undergoes scarring, toughens, and blends together as it heals. The variations in color and texture disappear. The intestines and bowel sometimes stick to the healing wound, putting them in harm’s way the next time surgery is performed.
With a first cesarean, the up-front costs - a few more days in the hospital, a longer recovery - may seem reasonable. Only in retrospect can the true costs become apparent.
Good luck, Dr. Friedman.
Beyond Medicine, a Doctor’s Urge to Save a Patient From Herself (December 12, 2006, New York Times). Friedman was criticized for his attitude toward female sterilization.
Wanted: Workaholics to Become Obstetricians (August 9,2005, New York Times)