For nearly three decades, I reminded every woman I saw in my family practice, from adolescence onward, to do a monthly self-breast examination (SBE). It made great sense in theory: the earlier you find a malignancy, the earlier you can treat it, and the better the outcome.
But when researchers looked at actual outcomes, they found that women who discover lumps when doing a routine self-exam live no longer or better than women whose tumor is found with an exam by a health care provider; a mammogram; or accidentally, by the woman herself or a lover. The one difference between the two groups was that the women who found lumps with a self-exam had more procedures, expenses and worry.
Based on solid evidence, the American Cancer Society recommended in 2003 that self-breast examination be optional for women over the age of 20. By 2015, ACS guidelines for women at normal risk (e.g., with no family history of breast cancer) didn’t even mention the SBE, nor even clinician exams. Mammograms, starting from the age 40 or 45, became the sole focus for screening low-risk populations. Of course, any woman who does find a breast lump (or man, for that matter) should see a provider right away.
Continuous fetal monitoring (CFM) is another of those widespread measures that makes much better logical than clinical sense. In the 1880s, midwives learned to assess the well-being of a fetus by counting the baby’s heartbeats, audible through a stethoscope applied to the mother’s abdominal wall. The modern cesarean section was added to the surgical armamentarium at about that time, providing a powerful option for managing fetal distress. Doctors could literally snatch compromised babies right out of their mothers’ wombs.
By the 1960s, monitoring technology had progressed to an ultrasonic gizmo, held against the mom’s belly with an elastic band, that could pick up the fetal pulse continuously and record it as a squiggle on a long strip of paper. Paired with a tocometer, which measures uterine contractions (and is also held against the mother’s abdomen and outputted to that same strip of paper), this gave health care workers a powerful way to track fetal well-being from moment to moment. Continuous fetal monitoring quickly became de rigueur. I spent a good deal of my medical school obstetrics rotation adjusting ultrasound and tocometer heads that had lost the signal.
Trouble is, when you compare the labors of women with low-risk pregnancies who have been monitored continuously to labors of women who have not, the babies come out about the same. But the continuously monitored mothers are subjected to significantly more interventions—oxytocin stimulation, forceps deliveries, episiotomies, C-sections, etc.—with their attendant expenses and complications. The critical phrase here is “low-risk pregnancies,” which is what most pregnancies are. For uncomplicated patients, fetal well-being can be assessed more than adequately by intermittently measuring babies’ heart rate with a handheld ultrasound device. There are still plenty of good reasons to monitor some labors continuously—just not most.
Moreover, despite reams of studies and guidelines about CFM, diagnosis of fetal distress based on monitor data is still dismayingly imprecise. Two doctors can look at the same strip and draw opposite conclusions. So far, artificial intelligence hasn’t helped much to distinguish reassuring from non-reassuring monitor tracings.
If there is any doubt about a baby’s well-being, professionals reflexively want to do something. Anything but a reassuring tracing heightens vigilance, steering the birth process down a path that may well lead to more intervention.
Mammals, including humans, move about a good deal in labor. Women naturally change position. They may thrash or pace. Making them stay still so that finicky electronic monitors can remain in position is unnatural. It inhibits a laboring mother’s instinctual movements that help her fetus find an optimal lie for its journey down the tight birth canal. Restricting her freedom of movement may cause a mother to experience more anxiety and pain, making it likely that she will require more labor-slowing pain medications.
Many labor and delivery units have now changed their protocols for low-risk pregnant women. Instead of automatically resorting to CFM, on admission staff obtain a “baseline strip” of about a half hour, just to reassure themselves that the baby is starting out okay. Once again, studies have shown that such strips too often nudge normal women with normal pregnancies who will deliver normal babies in the direction of instrumented or operative deliveries, with no better outcomes for their babies and more complications for themselves.
Many a doctor has acceded to routine CFM for her patients because she has asked herself, “What am I going to say in court, with the plaintiff sitting there before the jury, her pitiful ‘damaged’ child in her arms, when her attorney asks me, ‘So, in the absence of monitoring her continuously during labor, how did you know, Doctor, this poor baby was okay?’” Never mind that the vast majority of newborn problems have nothing to do with what happens during labor and delivery, nor that a fetal monitor strip is equally likely to hurt as to help a malpractice defense.
The best protection against being sued, study after study has shown, is a good relationship between provider and patient. Placing an electronic device between mother and professional doesn’t help. When I taught obstetrics to family medicine residents, I’d often have to remind these young doctors-in-training to stop and ask their laboring patient how she is doing before they walked over to the monitor to see what the strip appears to say about how she and her baby are doing. Practicing doctors too often forget the maxim that everybody learns in medical school, “When all else fails, listen to the patient,” let alone that it’s supposed to be sarcastic.
Women were glad to learn they didn’t need to be checking their breasts every month. It was one less thing to do or to feel guilty about not doing. And I was relieved to have one less thing to nag them about.
Diminishing routine use of continuous fetal monitoring has been much harder to accomplish. As of 2013, 89 percent of labors in the United States were monitored, 80 percent of those continuously. “Non-reassuring fetal heart rate tones” remains the second most common reason given for a first cesarean (after “failure to progress,” which means that it doesn’t look like the baby will come out on its own).
Unlike the self-breast exam, which is patient-initiated, the decision to do continuous fetal monitoring is essentially up to health professionals, who are likely too scared not to do something if it appears that something could be done. Trouble is, there’s a big difference between what could be done and what should be done. How we employ continuous fetal monitoring is but one example of the pervasive challenge of shifting medical practice from coulds to shoulds. Practice change depends much more heavily on adjusting attitudes, incentives and culture than it does on gathering and analyzing ever more data.