The evolution of fetal monitoring: a round-table discussion – part 2
Estimated reading time: 8-10 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 Diogo Ayres-de-Campos
Associate Professor, Medical School – University of Lisbon, and Secretary-General of the European Association of Perinatal Medicine (EAPM)
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 northern Colorado, USA
Midwife and former head of the labor ward at Universitäts-Frauenklinik Tübingen, Germany
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 second in a two-part series – our expert panel discusses changing public and clinical attitudes regarding freedom in labor, and sets out its hopes and visions for the future of fetal monitoring.
Q: How have public attitudes and expectations evolved in terms of the labor and birth experience?
Susanne Neye: In my time as a midwife, women have successfully fought for several changes. For example, partners may now accompany them to the birth, and the women themselves can move more freely or take baths during labor. In addition, the concept of ‘rooming in’ has become established – so women can have their newborn child in the room with them after birth.
There are also more options now for pain management, for example epidural anesthesia. In the past, this procedure was quite rare and even considered risky by some, but now it is a lot more established in everyday clinical practice – and I believe it is a real blessing for a lot of mothers.
Prof Dr Diogo Ayres-de-Campos: In the 1990s, it was widely believed that expectant mothers could not remain fully mobile while being continuously monitored during labor. This led many women to decline continuous monitoring during childbirth, and for the technology to be seen as providing a negative experience. Advances in wireless transmission of signals – driven to a large extent by Philips – now allow women to remain fully mobile during the whole process, while at the same time supporting continuous monitoring of the fetus.
Prof Sir Sabaratnam Arulkumaran: In general, I would say that women are playing a far more active role in the labor care decision-making process. They know more about their options than in the past, and they know that there is advanced technology available that can assist in monitoring, so they are more likely to request ambulatory monitoring than previously.
Q: What has changed in terms of the way in which obstetrical care is delivered – particularly to support greater freedom in labor?
Prof Dr Ayres-de-Campos: Healthcare professionals have had to adapt to the changing expectations of mothers-to-be for a more positive and relaxed experience during pregnancy and childbirth. In this sense, it’s not just about the technology – it’s about incorporating it wisely into clinical care, and focusing more on adequate communication with patients, as well as effective interactions with other healthcare professionals.
Ms Neye: Public attitudes have certainly changed, with more and more women wanting to experience freedom in labor at their own pace. Movement can be extremely helpful in advancing the birth process and easing labor pains. It is often better to be mobile during labor than to lie on a bed in a fixed position, unable to do anything else.
With that in mind, we strive on a day-to-day basis to help mothers to stay mobile during labor. In certain situations, the mother’s mobility may be restricted – such as if we detect an unusual fetal heartbeat pattern and therefore need to perform continuous monitoring. Unfortunately, this type of monitoring isn’t always possible in every birthing position.
Suzanne Ketchem: We have realized that being confined to a bed is simply not the best way to go through labor. This mind shift was initially driven by the mothers themselves who started saying: “But it feels better to be moving around.” And thanks to evidence-based research and education, we know that they are absolutely right. In the past, we might have been reluctant to let them out of our sight, but with the wireless monitoring technology we have today, we’re happy to let them move around the entire unit freely, because we can still keep track of both mom and baby.
Q: Looking ahead, which advances would you like to see that would improve your job or the mother’s labor and childbirth experience?
Prof Dr Ayres-de-Campos: I would like to see evidence that the quality of fetal monitoring remains high at all times during mobility, without the need for invasive techniques such as fetal scalp electrodes. I also hope that innovations will allow a more objective and non-invasive monitoring of labor progress. Repeated vaginal examinations are uncomfortable and provide very subjective information.
Beyond that, I feel that computer analysis may be of help, allowing a more objective and discriminative method of assessing fetal oxygenation and labor progress. With all major aspects related to safety taken care of, healthcare professionals can focus more on the human side of labor, allowing women to fully enjoy the positive experiences of childbirth.
Prof Sir Arulkumaran: Firstly, we need to make further progress in artificial intelligence and machine learning for the interpretation of CTG – finding out whether computers can assist in providing a better level of knowledge to both the clinician and the mother. Secondly, it would be valuable to develop a technique to measure pH or lactate in fetal blood using minimally invasive techniques; again, this data would provide a great deal of insight and reassurance.
Finally, we should strive to make the labor and birthing environment as unintimidating, welcoming and natural as possible; a calm, clean, low-tech environment with ample space to move. When a woman, her partner or her family or friends enter the labor room, it is so important that they have a positive impression from the start. Even the color scheme, access to natural light or the ability to see through a window will make the room more natural and less stressful.
Ms Neye: As a midwife, I would ideally like to be able to offer one-to-one care – but even one-to-two care would represent major progress on a day-to-day basis. I want to offer women a calm, peaceful birthing environment, with few interventions and little external interference. Ultimately, it’s about being there when mothers need us, while allowing them time and space to be alone with their partners, for example.
It would also be useful if CTGs could somehow provide additional information on how the child is currently doing – so that we can assess whether everything is OK or we need to intervene. In addition, it can sometimes be difficult to monitor the heartbeat of high-BMI patients unless the mother remains in a very specific position. This can heavily restrict the woman’s freedom of movement – so I would certainly welcome new advances in this area.
Ms Ketchem: I would like to see further advances that support the idea of birth as a natural process. We’ve started on the right path and I’d like to see this continue. What’s more, I would welcome technologies that support the birthing experience as an inclusive, multi-disciplinary event – supporting collaboration and involvement of everyone, including the moms.
In terms of improving my work, I’d love to see technology become more invisible. I need accurate data, of course, but I don’t want to feel like the equipment is coming between me as the nurse and the patient I am caring for during labor and birth. We’re definitely on the right track here too.
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