Kathleen is in the hospital having her first baby. The rhythmic thump-thump, thump-thump, thump-thump of the external fetal monitor, which loudly projects the unborn baby's heartbeat into the birthing room, is reassuring to Kathleen and to her husband. This type of monitoring is called Electronic Fetal Monitoring (EFM). It is commonly used to assess the fetal heart rate of a baby during labor. The fetal heart rate gives an indication of how the baby is tolerating labor and if he or she is receiving sufficient oxygen.

An ultrasound sensor is placed on the laboring mother's abdomen and is usually held in place by an elastic belt. It is commonly used in conjunction with a pressure-sensitive transducer to assess strength, duration, and frequency of uterine contractions. Together, they create a printout that shows a beat-to-beat reading of how the heart rate changes during and between contractions.

Hospital practices. Most hospitals have a rule that requires initial monitoring for about 20 minutes. If the printout looks reassuring, some allow intermittent monitoring, either with the monitor strapped on or with a handheld ultrasound device called a Doppler. Some require monitoring during the entire labor, and some places want continuous EFM during labor to document any problem as a legal protection in case of a malpractice.

For some women and their healthcare providers, continuous fetal monitoring provides reassurance of infant well-being during labor. Whether continuous or intermittent, electronic fetal monitoring provides information to healthcare providers on how the infant is tolerating labor. This information can lead to changes in the management of labor; these changes include giving the mother oxygen, having her change position, stopping labor-inducing medication and, at times, quickly delivering the baby by forceps or by methods such as vacuum extraction or cesarean section.

Continuous versus intermittent monitoring. Continuous monitoring is beneficial to high-risk patients, including women induced with pitocin or women who have thick meconium (infant stool) in the amniotic fluid, but its benefits for low-risk mothers are unclear. Both the American College of Obstetricians and Gynecologists and the U.S.
Preventive Services Task Force say laboring women need some form of fetal monitoring, yet they reserve continuous fetal monitoring for high-risk cases. Continuous EFM is used in the majority of births in the United States, but medical literature still contains much debate about its efficacy for low-risk women. Studies have shown that continuous monitoring is not more effective than intermittent monitoring. Other studies have shown an increase in interventions such as vacuum extraction, cesarean sections, and the use of forceps for women who are monitored continuously, with limited benefit to the baby.

According to Phyllis Rattey, CNM, of Special Beginnings Birth and Women's Center in Arnold, Maryland, the reason for the increase in interventions in the normal birth process for women who are continually monitored could be due to "inaccuracies in interpreting the monitor strip, simply seeing a bad strip and not looking for ways to help the baby do better, but instead jumping to an intervention to deliver the baby right away." She continues, "Decreases in heartbeat are common during labor, especially during a contraction. By using a machine instead of midwives, nurses, and doctors to provide care, decisions might be made too quickly, instead of looking for simple ways to provide improved oxygenation for the baby."

Continuous fetal monitoring for high-risk cases. Many people think that continuous fetal monitoring should be used only when there are significant risk factors for complications. According to Connie Breece, CNM, of the Cambridge Birth Center/Cambridge Midwives, in Massachusetts: "EFM is useful when a baby is stressed, such as when there is thick meconium, the mother has a fever, or there is an obvious problem with the placenta, or when the baby isn't tolerating the stress of labor well. For healthy moms and babies in labor, intermittent auscultation of the fetal heart with a handheld monitor is sufficient."

Most midwives and doctors would agree that high-risk patients should be closely monitored. "There is a role for this type of monitoring for women who are receiving labor inducing medication or for women who have not had reassuring fetal heart tones early in labor," Rattey says. She worries that this method of monitoring during labor places too much attention on a machine instead of taking cues from the mother. But for Kate Bauer, who delivered at New York Hospital in New York City, the fetal monitor strip "gave my husband, who is very scientific, something to focus on, and it helped him understand what was going on during labor and with the baby."

According to Breece, "Many patients choose out-of hospital births to avoid monitoring and other interventions that might hinder labor."

Intermittent fetal monitoring. In out-of-hospital births, and for many midwives and doctors, electronic fetal monitoring for low-risk women is used intermittently. The baby's heart rate is heard through a Doppler both during and after contractions, or for short-term periods with the fetal monitor attached to the mom. Some Dopplers can be used underwater, and this new technology frees the mother to use a tub or a shower to increase comfort.

"At the hospital and at the birth center, we carefully monitor the patients through intermittent monitoring during and after contractions, and we observe the amniotic fluid, the mother's temperature, and other signs," Breece comments.

Karin Theophile of Takoma Park, Maryland, was induced during her first pregnancy because her baby was large. After a day of labor, the fetal monitor showed the heart rate decreasing during contractions, and she had a cesarean section. When she was attempting a VBAC (vaginal birth after cesarean) and being induced with her second child, she was very frustrated by all the "attachments"-the IV, the epidural and, worst of all, the tight straps of the monitor belts.

Nevertheless, Theophile understands the importance of all of this technology and feels that it was necessary in her case. "The most important thing in labor is that you know the baby is okay and that you have a trusting support group," she says.

Other forms of fetal monitoring. Internal monitoring is another form of electronic monitoring. It requires that the amniotic sac be broken spontaneously, or by the midwife or doctor, and that the women be at least 2 cm to 3 cm dilated. A scalp electrode is passed through the birth canal and attached directly to the baby's head. This type of monitoring provides a more accurate reading of the fetal heart, as you can pick up maternal heart rates or lose the signal during contractions or from the mother's movements.

The newest type of monitoring uses telemetry and radio waves. A transmitter is connected to the mother's body, usually on the thigh, and fetal heart tones are transmitted to a remote area, usually at the nurses' station. Women in labor have more mobility and fewer wires and connections with this type of monitoring.

Know your options. Each woman, birth, and healthcare facility have different needs and standards. It's most important for expectant parents to be familiar with the methods of fetal heart monitoring used by their healthcare provider and by the place where they will give birth. For example, a facility might be unwilling to conduct intermittent monitoring for a couple that wants it. Therefore, a couple's expectations for fetal monitoring during labor should be discussed during prenatal care, and if the facility or provider is unable to accommodate a low-risk patient, she might choose to give birth elsewhere. Women who are high risk, who are being induced, or who choose an epidural will be more likely to have continuous monitoring.

*taken from "Heart Beats" by Lois Wessel, Every Baby magazine, Issue Four.