I have represented many families in birth injury cases. I have reviewed many, many potential birth injury cases that I did not accept. In every one of those cases, the fetal heart monitor strip was an essential piece of evidence. Just how reliable is it?
Birth injury cases have resulted in many of the largest medical malpractice verdicts. These cases are incredibly sad and usually involve very badly damaged infants or babies who died during or shortly after birth. If the infant survived, she or he was usually in need of a lifetime of expensive care. Verdicts exceeding $10M are not uncommon.
Fetal heart monitors (FHM’s) were developed in the 1950’s. They use sensors to record the baby’s heart rate and the mother’s contractions during labor. In the image above, the baby’s heart rate is shown in the upper portion and the mother’s contractions in the lower. Prior to the development of FHM’s, obstetrical nurses listened to the baby’s heart with a stethoscope. One of the selling points of the FHM was that it permitted continuous monitoring of the baby’s heart rate.
Although there was very little research at the time about the predictive value of a FHM in a normal labor, they were adopted widely. A hospital which does not use this technology today would be at a serious disadvantage in the event of a birth injury lawsuit. Since all of the other hospitals are using continuous fetal monitoring, the family of the injured child would very reasonably ask why this hospital did not and argue that continuous monitoring would have prevented the birth injury.
As FHM’s became widely used, the rate of Caesarian sections rose dramatically. Now one of every three deliveries takes place, not in a delivery room, but in an operating room. This rate of Caesarian section deliveries is much higher than public health experts believe it should be. It obviously increases the cost of the delivery and exposes both the mother and the child to risks not found in normal, vaginal deliveries. A Caesarian section may prevent the mother from having children in the future or may greatly increase the risks of a subsequent labor and vaginal delivery. Some obstetricians are of the opinion that once a woman has a Caesarian section, she should never attempt to deliver vaginally again.
Of course, any test is going to produce both false negatives and false positives. No test is perfect. When it comes to FHM’s, false positives are going to lead to unnecessary Caesarian sections. Also, a test is no better than the health care provider who interprets that test. The interpretation of FHM strips is not black and white. What one person interprets as concerning, another may find inconsequential. Also, lazy obstetricians who want to go home and go back to bed may recommend a Caesarian section to a laboring mother when the FHM is equivocal or otherwise not truly showing the presence of a medical emergency.
So what to make of the criticisms of FHM’s? Are they “worthless” or “pathetic” as some obstetricians have claimed? Or are they a potentially valuable tool in the hands of the right person? It is often difficult to assess criticisms like these when the people making them may have a vested interest in attacking the credibility of the FHM. As I mentioned above, FHM’s are often the most critical piece of evidence against the defendants in a birth injury case. If their predictive value is discredited, they are not going to be useful in demonstrating that the baby was in trouble and needed to be delivered promptly. Then the only remaining voice in the courtroom is the obstetrician. How convenient for the obstetrician.
I land on the valuable tool in the right hands side of the argument. More study would be nice, but no one in the medical establishment seems to be in any hurry to undertake such a study. The fact that obstetricians and all hospitals continue to use FHM’s is strong evidence that they believe they provide important information and have some predictive value.
As in so many other areas of medicine, it never hurts to have an intelligent, caring physician as your obstetrician. Such a physician may not always get it right and may make a mistake from time to time, as do we all, but such a physician is the best hedge you and your baby have against medical catastrophe.
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