[Disputes and history of fetal heart monitoring]. / Controversias e historia del monitoreo cardiaco fetal.

The concept of fetal heart monitoring to determine the fetal wellbeing state has been employed for almost 300 years, but in the last 50 years it has observed drastic changes due to the incorporation of the electronic devices that has started controversy since the moment of its description and point of start. The purpose of this article is to mention the key points and controversial moments in the history of the cardiotocography

Surveillance during labour.

The technology of intrapartum surveillance made rapid strides from the 1960s through the 1980s but then stagnated as increasing resort to caesarean section was made rather than improving measures of fetal condition and labour progress. However, despite caesarean section rates commonly over 30%, medicolegally expensive mistakes continue to be made because it is difficult to teach clinicians to make reliable use of existing technology. It may be that as with aircraft navigation, the safest solution is to replace human judgement with the obstetric equivalent of automatic pilots.

From innovation to common practice: perinatal nursing pre-1970 to 2005.

The history of perinatal nursing from before 1970 to the present is characterized by innovations that became common practice in later years. These innovations include fetal monitoring, mother/baby care, and early postpartum discharge. The driving forces behind changes in care within the social context of the times were scientific/medical developments and families' desires for the best possible childbearing experience. With innovations becoming commonplace, nursing practice became more complex. How nurses approach present-day challenges of increasing technology of birth, looming threats of litigation, and providing care under time and economic restraints is continuing to evolve.

Intrapartum assessment of the fetus: historical and evidence-based practice.

The principal purpose of intrapartum fetal assessment is to detect hypoxemia-ischemia, which may lead to fetal jeopardy. A quarter century ago, electronic fetal monitoring replaced intermittent auscultation as the primary method of intrapartum fetal assessment in the United States. It seems that electronic fetal monitoring will continue to be the primary mode of intrapartum fetal assessment, with intermittent auscultation used in some centers primarily for low-risk parturients. From this abridged history of intrapartum fetal monitoring, it is recognized that all surveillance methods bear inherent limitations.

The partograph. Used daily but rarely questioned.

The partograph is part of the midwifery tools of practice, used everyday, but rarely questioned. This paper explores the history of the partograph and describes its development from 1954. It examines the components of the partograph and discusses when one should be commenced. The value of the partograph in practice today is questioned.

Retrofitting technology to nursing: the case of electronic fetal monitoring.

OBJECTIVES: To describe how nurses put electronic fetal monitoring to use in the 1960s and 1970s and the dilemmas this caused. DESIGN: Social history. RESULTS: Nurses used electronic fetal monitoring to improve the watchful and comfort care of childbearing women, and they saw it as validating nursing. They retrofitted, or worked to reconcile machine monitoring with natural, prepared, and participative childbirth, and with attentive and embodied nursing. CONCLUSION: Electronic fetal monitoring was another in a long line of technological innovations that fell to nurses to put into use and to make work. The remarkably rapid way electronic fetal monitoring became routine in the United States depended, in large part, on the articulation work of nurses. However, like all such work, what nurses did to make electronic fetal monitoring work for patients, physicians, hospitals, and manufacturers was largely invisible. Retrofitting efforts often entail unrecognized innovation and risks for nursing.

Intrapartum fetal monitoring: past, present, and future.

The concept of intrapartum "monitoring" of the fetal heart rate by auscultation has been extant for almost 200 years and by electronic means for more than 30 years. This article explores historical aspects of fetal monitoring, the advent of electronic fetal monitoring and its controversies, and present and future research opportunities to enhance the reliability, validity, and efficacy of fetal monitoring.

The medical and legal risks of the electronic fetal monitor.

Electronic fetal heart monitoring (EFM) is the most widely used method of monitoring the fetal heartbeat for possible signs of distress during delivery. Soon after its development in the 1960s, EFM replaced intermittent auscultation as the standard of care in the obstetrical community. However, Margaret Lent argues that the widespread use of EFM is both medically and legally unsound. Lent points to a series of clinical trials that demonstrate that EFM does not reduce fetal mortality, morbidity, or cerebral palsy rates. These studies suggest that EFM has a very high false positive rate, and that EFM usage correlates strongly with a rise in cesarean section rates. Similarly, EFM provides no protection in the courtroom. Though obstetricians believe that they should use EFM because its status as the standard of care will protect them from liability, Lent argues that it may in fact expose them to liability given its failings. Instead, she argues that auscultation is equally, if not more, safe and effective, and is more likely to protect physicians from liability. Lent concludes that obstetricians have an obligation to their patients and to themselves to adopt auscultation as the new standard of care.

Principles of nonstress testing in pregnancy.

The nonstress test has been used to document second and third trimester fetal well-being for the past 40 years. It serves as a surrogate measure of the developing fetal autonomic nervous system. The nonstress test is more specific than sensitive, thus being a better indicator of fetal health than fetal illness. The test itself is read as reactive or nonreactive and may be repeated at intervals as a screen for high-risk maternal conditions.

Historical perspectives: forgotten past, unpredictable future.

Intrapartum surveillance has in recent years become a matter of debate. Following its earlier development, first in auscultation and then 40 years ago in electronic monitoring, obstetricians accepted its use with great, perhaps too great, enthusiasm. Years later, attempts to evaluate the actual consequences of this use led to disappointment: although its benefit on perinatal mortality is acknowledged, two observations lead one to reconsider the legitimacy of its use. First the apparent lack of beneficial influence on neonatal long-term morbidity, and second the definite increase in the rate of caesarean section. Furthermore, recent comparative studies, despite some discrepancies, seem to indicate that clinical monitoring by auscultation leads to results as good as those from electronical monitoring, particularly with respect to fetal mortality and infant morbidity. These observations obviously merit careful consideration; some explanations may be put forward to explain these apparently surprising results. From a practical point of view, this discussion leads to two opposite choices for obstetric policy: either to 'go back' to auscultation or to try to identify indicators more specific to fetal asphyxia and increased risk of cerebral palsy, leading to more precise and fewer indications for caesarean section. This chapter on historical perspectives may be useful in pointing out what were the goals of the obstetric pioneers involved in electronic monitoring: definitely not to build theoretical considerations on the pathophysiology of fetal distress, but to gather continuous information about the fetal heart rate in the hope of detecting changes announcing fetal asphyxia before it becomes irremediable, and hence preventing fetal death. These promises have been fulfilled. It follows that continuous clinical monitoring, which provides the same kind of information, is quite likely to lead to similar clinical results. It also follows that this relatively cumbersome method has really nothing to do with the 'classical' clinical surveillance in use before the widespread acceptance of electronical monitoring. It may be beneficial to experiment with this specific type of clinical surveillance; it would be dangerous, however, to 'go back' to the type of monitoring practised 40 years ago.