The evolution of fetal monitoring: a round-table discussion – part 1
Estimated reading time: 7-9 minutes
Discover insights from leaders in obstetrical care on how the labor experience has changed for caregivers and for mothers in the last 50 years.
Prof Dr Harald Abele
Deputy Medical Director at Universitäts-Frauenklinik Tübingen, Germany, and full member of the Faculty of Medicine at the University of Tübingen
Prof Sir Sabaratnam Arulkumaran
Professor Emeritus at St George’s University of London, UK
Senior Director of the Women & Children’s Service Line, UCHealth in northernColorado, USA
Dr Deborah Fox
Lecturer in Midwifery at the University of Technology Sydney, and Member of the Scientific Review Advisory Committee of the Australian College of Midwives
2018 marks 50 years since the launch of the first commercially available non-invasive fetal monitor, developed in collaboration between Professor Konrad Hammacher and HP Medical, now part of Philips. Since then, we have played an active part in shaping trends in obstetrical care – a field that has evolved beyond our imagination.
As part of our celebrations to mark this historic anniversary, we invited clinical opinion leaders from around the world to share their perspectives on the developments they have witnessed in obstetrical care. In this post – the first in a two-part series – our expert panel discusses the role of technology in obstetrical care, and considers how the labor experience has evolved from the mother’s point of view.
Q: How have technological advances changed the way you work?
Prof Sir Sabaratnam Arulkumaran: I think that obstetricians have been greatly assisted by advances in fetal and maternal monitoring technology. Compared to when I first entered obstetrics, the clinician is now better placed to reassure the mother by promptly detecting and monitoring issues that could arise.
Technology has helped mothers, too – by allowing them to choose what is most comfortable for them. If the mother wants to get into the pool, for instance, we can use waterproof transducers so that she can still be monitored without any difficulty.
Suzanne Ketchem: When I began my career as an obstetrical nurse 35 years ago, childbirth was considered a medical procedure. Back then, the patient was admitted to a sparsely decorated labor room with only a bed, night stand and clock. Patients were only allowed to ambulate to the bathroom, and only one support person – usually the father – could be in the room with them during labor.
Today, it’s a completely different story. Mothers and their babies are monitored using palpation and auscultation or electronic maternal/fetal surveillance throughout labor and we can keep a closer eye on them – even when we’re not physically in the room. Additionally, moms are encouraged to move around as often as they desire, take a bath, and assume whichever position is comfortable for them. And because of the incredible advances in technology, we can still monitor them continuously.
Prof Dr Harald Abele: In the past, we moved from bed to bed and room to room to monitor each mother and fetus, but now we have central monitoring systems that allow multiple caregivers to check for changes in maternal blood pressure and fetal heart rate, or to review CTGs, pulse rate data and so on. These technologies are an integral part of modern-day obstetrical care. However, they only provide indirect indications of how the mother and child are doing; that’s where the experience of the obstetrician continues to play a greater role.
Dr Deborah Fox: Out of all the advances I’ve seen in over a decade as a midwife, I would particularly highlight cordless waterproof fetal monitoring technology. I think it has been crucial in enhancing how we support women who require continuous fetal monitoring during childbirth. It offers the quality and continuity of traditional wired fetal monitoring, while enabling a superior labor and birth experience, increasing the chance of a normal vaginal birth and lowering the likelihood of requiring significant interventions.
I’ve been working with Philips to help spread awareness of this technology among clinicians in Australia. Having seen the benefits first-hand, I feel it’s important to get the message out there.
Q: Have any developments surprised you during your time in obstetrical care?
Dr Fox: I’ve been pleasantly surprised by progress in developing technology that allows women with complications to have a normal birth. Also, even though I’ve been aware of cordless waterproof technology for a decade now, the ability to wirelessly monitor twins and triplets, and maternal blood pressure and oxygen saturation, has certainly been a significant innovation.
Beyond that, I would also highlight advances in fetal surgery as a very exciting area of development, with a view to improving babies’ health.
Prof Sir Arulkumaran: I would highlight the significant advances in diagnostic capabilities. In particular, I have been pleasantly surprised by the huge progress in non-invasive pre-natal screening. Now, it is possible to take a small sample of maternal blood and perform a range of incredibly valuable assessments, such as chromosome analysis for trisomy 21, 13 and 18.
The progress in obstetrical care has fed into other areas of medical science, too. Non-invasive pre-natal screening of maternal blood was initially developed to help clinicians detect fetal problems, but similar techniques are now used in the diagnosis of cancer. Ultrasound monitoring, too, is now used in a far wider range of clinical applications than obstetrics alone.
Prof Dr Abele: One thing I have observed is a trend towards ‘defensive medicine’, with legal considerations and safeguards becoming increasingly important – not least in decision-making for clinical procedures. We also need to be able to use the data we obtain as a form of verification; that’s a question of monitoring and documenting everything as well as we can.
I’ve also noticed that obstetrical care has become increasingly service-driven. I remember my earlier days on the labor ward, in the mid-to-late 1990s, when we had one station, 17 beds and one toilet. Today, as soon as we have three or more expectant mothers in a single room, we receive complaints. This is less about the quality of care we provide during labor and birth, and more about offering a pleasant environment and the right logistics. Today, hospitals often focus on these aspects when marketing themselves.
Q: How has the experience of labor and childbirth evolved from the mother’s perspective?
Ms Ketchem: It’s changed immensely. In the past, we’d talk passively about ‘delivering a woman of her baby’; the doctors would make the decisions, the nurses would follow their orders, and the woman’s wishes and requests were not considered by the doctor. Today, mothers are highly informed about their choices and come with expectations and birth plans that are followed by the care team to the best of their ability. Additionally, there are so many more birthing options available to the mother, including alternative locations and positions. The entire care team works hard to accommodate the mothers’ wishes and to make the entire birth experience as flexible as possible.
Dr Fox: Women are becoming more informed about their options, and I think that’s something we should embrace. The more information we can share with them to help them make choices, the better. While the midwife is the expert in childbearing, the woman is the expert in her own life and needs, and those of her family. Those two things have to go together, and that means understanding and responding to the mother’s emotional, psychological, cultural and social needs – rather than treating childbirth as a purely medical procedure.
Prof Dr Abele: Whenever I discuss this topic, I like to show people photographs of babies and mothers from 40 years ago. The picture of the baby is much the same now as it was then, aside from the improvement in image quality and the move from black-and-white to color! It’s the image of the woman, the mother, that has changed enormously – the perception of what is ‘ideal’.
Some of these changes can be linked to the service-driven nature of obstetrical care today. Women come into the care environment and expect to be healthy, and for everything to go well during their stay. It’s like when they go into a hotel and are disappointed if the room doesn’t look as good as it did in the pictures. Of course, any disappointment is greater in the field of medical care because it’s about health, which is of fundamental importance to us all.
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