Fetal heart rate monitoring- sort of want to skip it altogether?

[RabbitMomma]

So we just met with our midwife last night to discuss some of the logistics of our home birth plan, and something that came up was fetal heart rate monitoring. I did not think that I wanted to have any fetal heart rate monitoring at all unless there was an apparent reason to during the labor, simply because I really thought that it would interfere with my mindset and concentration during labor. However when I told my midwife this she seemed sort of hesitant, and told me to think a bit more about it. She said that in terms of monitoring how the baby's doing, that this is one of the few ways she's able to check in on it. In the end she'll support my decision either way, but I really think that she wants me to have some fetal heart rate monitoring.

Now I'm just a little confused about what to do. It's one of those things that's not really overly intrusive or harmful, just more of an annoyance really. What I'm wondering is what are some typical problems that fetal heart rate monitoring can detect, and if it does detect it, what can be done about them? I'm also wondering that if there is a problem where the baby is in distress, would there really be no other way to tell other than heart rate monitoring?

Anyway I'm really having a hard time deciding this one and would really love some insight from other mamas about what they decided and why!

[Mama2Kayla]

Please dont skip monitoring! Why wouldnt you want to know how your baby was tolerating labor? Im not a birth professional, but Im sure there is really no other way to tell if your baby is going into distress before it's too late.

Your midwife is hesitant for a reason...it's not safe

[AlexisT]

There's 2 issues here:

1) FHR monitoring can tell you how the baby is doing. You want to make sure the baby is still doing well. You can't tell in advance whether there's a need for it or not. Labors go south without notice.

2) If something does go wrong, and there is no record of monitoring, your midwife is potentially on the hook for negligence. Checking the baby during labor is the standard of care.

[kltroy]

So what you're really asking is: what can FHR detect?

The main thing is reactivity.  During a ctx, baby's HR slows down b/c baby is being squeezed and doesn't get much blood.  When the contraction is over, baby's HR should recover (ie speed back up). If it doesn't this can indicate a problem/baby in distress.  Another thing they look for is variability - that is, does the HR stay "too constant" or does it go up and down within a range, which is healthy?  Also, if baby's HR is too fast, that can be a sign of stress/distress.  In fact, this is a key indicator of uterine rupture (mostly a concern for VBAC). 

So no, I wouldn't skip the HR.  Believe me - when you're in "laborland" you won''t even notice it.  Anyway, what's the point of having a MW if you're not going to let her do her job?

[APToddlerMama]

I can't even remember DS's heart rate being monitored but I know it was, and I'm glad, because after 2.5 hours of pushing, his heart rate began dropping and we knew he needed to get out right away, and had to use the vacuum.  There were no other indications that things weren't going smoothly.  I had a really easy labor until around 9cm.  It is hard for me to imagine keeping an eye on heart rate really disturbing and disrupting labor.  I am the type who gets annoyed by things like scratchy tags on my clothes, but like pp said, when you're in "laborland" little stuff like heart rate monitoring doesn't even flash across your mind.  You have way bigger things to focus on.  Things may go perfectly fine, but if your babe's heart rate starts dropping, you want to know...

[cat13]

OP, I don't mean to take over your thread, but I have a question. When you say "fetal monitoring," do you just mean that your MW will use her dopplar throughout your labor? Or does she have something like the hospitals have where they strap the monitor around your belly? Is that something that can even be used in a home birth?

[AlexisT]

Supposedly, there are a few midwives who have access to a CTG machine. I have only ever heard this presented as a possibility and never actually heard of it being done. Also, interpreting an EFM strip is an art that takes practice, which a midwife in an exclusively home birth practice may not get.

Two midwives were involved in this discussion, and said the same thing I initially felt--"If you need continuous EFM, you are not a low risk birth and should be in a hospital." Low risk births don't need EFM.

[womenswisdom]

To answer your question, there really is no other way to know if the baby is having a problem other than monitoring the heart rate. The midwife should be able to monitor with a handheld Doppler in whatever position you are in. They are looking for reactivity (that the heartrate has some accelerations and isn't static) and checking to be sure the rate is within a normal range (too low or to high can indicate a problem).

[Comtessa]

Originally Posted by AlexisT 

Supposedly, there are a few midwives who have access to a CTG machine. I have only ever heard this presented as a possibility and never actually heard of it being done. Also, interpreting an EFM strip is an art that takes practice, which a midwife in an exclusively home birth practice may not get.

Two midwives were involved in this discussion, and said the same thing I initially felt--"If you need continuous EFM, you are not a low risk birth and should be in a hospital." Low risk births don't need EFM.

Continuous EFM is not the same as intermittent EFM.  CEFM is the strap-across-your-belly variety that spits out a strip of paper.  Annoying, unnecessary, and not evidence-based care.  In fact, it can increase your likelihood of an unnecessary C-section if you're low-risk.  But intermittent EFM with a Doppler is a simple, occasional quick check to listen to the baby's heart rate.  It is very non-invasive and -- in my experience -- doesn't even break into your awareness later in labor.  In a HB environment, you really only have four pieces of feedback to let you know how the baby's doing: your intuition, your MW's intuition, your physical symptoms, and the baby's heart rate.  It seems to make sense, IMO, to be staying aware of all four of those pieces of information so that you can be sure you're safe and labor is going well. 

My labor was VERY long with DD -- three full days.  But since my MW checked the baby's HR frequently, we knew that baby was handling labor well and I was doing fine, so there was never any cause for panic about the length of my labor.  Without EFM, I wouldn't have had that reassurance that things were going OK, KWIM? 
 

My MW had me use pee-strips every few hours to check on how I was doing, and at one point the strip indicated high ketones.  Baby's HR indicated slight stress at the same time.  This feedback helped her to encourage me to drink a LOT more and eat something.  Baby's HR went back to normal.  This is one of those instances where NOT getting that feedback could have led me into a bad place with labor, but having it meant that I could head off any serious problems with a simple intervention (in this case, grape juice and toast). :) 

[Turquesa]

During my labor, I was hyper-focused on doing my yoga breathing exercises during contractions.......so hyper-focused, in fact, that I didn't even know that right there in front of me, panic was ensuing because one of the Dopplers wasn't working, and they had to call for another MW to bring a working one over!  Trust the voice of experience: Intermittent Doppler monitoring is NOT invasive!  I get it when women turn down constant vaginal exams or IV hook-ups "just in case."  But I honestly wouldn't worry about something as beneficial and non-invasive as this form of monitoring. 

[AlexisT]

Yes - when I say EFM, I mean continuous EFM with a CTG machine (ie the belts and the strip). If I meant Doppler monitoring I would say intermittent ascultation. All babies need their HR checked, but not everyone needs continuous monitoring; that was my point.

[cat13]

Originally Posted by Comtessa 

Continuous EFM is not the same as intermittent EFM.  CEFM is the strap-across-your-belly variety that spits out a strip of paper.  Annoying, unnecessary, and not evidence-based care.  In fact, it can increase your likelihood of an unnecessary C-section if you're low-risk.  But intermittent EFM with a Doppler is a simple, occasional quick check to listen to the baby's heart rate.  It is very non-invasive and -- in my experience -- doesn't even break into your awareness later in labor.  In a HB environment, you really only have four pieces of feedback to let you know how the baby's doing: your intuition, your MW's intuition, your physical symptoms, and the baby's heart rate.  It seems to make sense, IMO, to be staying aware of all four of those pieces of information so that you can be sure you're safe and labor is going well. 

My labor was VERY long with DD -- three full days.  But since my MW checked the baby's HR frequently, we knew that baby was handling labor well and I was doing fine, so there was never any cause for panic about the length of my labor.  Without EFM, I wouldn't have had that reassurance that things were going OK, KWIM? 
 

My MW had me use pee-strips every few hours to check on how I was doing, and at one point the strip indicated high ketones.  Baby's HR indicated slight stress at the same time.  This feedback helped her to encourage me to drink a LOT more and eat something.  Baby's HR went back to normal.  This is one of those instances where NOT getting that feedback could have led me into a bad place with labor, but having it meant that I could head off any serious problems with a simple intervention (in this case, grape juice and toast). :) 

Thanks for the explanation!

[Smokering]

I'll just add that you can even get waterproof Dopplers, so you don't even have to get out of the birth pool for the MW to check heart tones. At my recent birth, monitoring was incredibly non-invasive - I think my MW checked the heart tones four or five times (It was a short labour!), and I was standing and swaying, rocking on my hands and knees, in the birth pool, on the floor... She just got down on the floor when necessary and held the Doppler where she needed to for a minute or two.

If you're anti-ultrasound , you could ask the MW to use a fetoscope instead. I imagine it'd be a trifle more of a pain, though; you might have to stay still while she listened, for instance. And I'm not sure how easy it'd be to hear the heartbeat during the pushing phase. It might be fine, I dunno - I mostly requested the fetoscope at prenatals, but was happy with Doppler use during labour itself.

I declined plenty of things, including all vaginal exams during labour; but I agree with PPs that this is a really good form of monitoring to have. Plus, it's nice to hear the baby's heart during labour (if you're not so deep in labour-land you ignore it altogether!) - it reminds you that these contractions are happening for a good reason, and that there's a little person in there, ticking away, waiting to meet you. And that's pretty cool. :)

[rebirth]

I disagree that intermittant doppler monitoring is not invasive. I have a different perspective, being a birth assistant, but since I know what FHT can indicate, I felt that in my labor and pushing they were disturbing and intense for me. He did have heart decels, late ones, and it was an indicator that he needed to be born soon, but it took me out of my labor land and into a place of fear. I will be requesting fetoscope monitoring only next time, so I personally do nopt have to hear how baby is... this will allow me to stay in tune to my intuition and away from a place of fear/panic. I will have monitoring trhough, and do feel it is unwise to not have any.

[MegBoz]

As other have said, you could request the use of a fetoscope, but you may have to lay on your back (not sure) & you may have to be still... so it's a trade off, IMO on which you personally find more disruptive. But I don't advocate NOT monitoring FHR at all... I mean, if you chose HB with a MW that means you want a trained medical professional there in case something goes wrong. I don't see the point in having the MW there if you aren't going to let her do the minimum of what she needs to evaluate in case something goes wrong- and FHR is part of that "minimum" of data she needs.

You might want to make sure they keep the volume on the doppler low though. I don't remember FHR checks irritating me during my HB - and they probably checked every 15-20 min of the 26 hours of labor I spent at home (well, MW & asst were there for 20 hours). However.. I got a bouncey seat for DD and one of the sound effects is a "ssshhhhh ---BA BUM" sound that is very much like the doppler. It was a little hard for me to hear - taking me back to the birth that was really, really rough on me. But, at the time, I don't remember FHR checks bothering me at all. Actually, the reassurance that DD was tolerating labor well was a welcome thing.

[Vaske]

Our midwife was able to use headphones with her doppler, so I didn't hear it at all, and the checks didn't bother me in labor.

[lamamaloca]

What I'm wondering is what are some typical problems that fetal heart rate monitoring can detect, and if it does detect it, what can be done about them?

Fetal heart rate monitoring is basically the only way we can know whether or not baby is tolerating labor. Certain patterns -- lack of reactivity and variability, certain patterns of decelerations, abnormally high or low heart beat, -- can indicate that the baby isn't tolerating labor well, indicate potential infection, help catch placental abruption, and identify cord compression. What can be done? If the heart rate is concerning different positions may be tried, if it is concerning enough you may have to transfer to hospital for continuous EFM or emergency delivery. Fetal monitoring (whether EFM or IA with a doppler) has significantly reduced the intrapartum still birth rate.

Although I do disagree with the above poster. In typical medical terminology, intermittent EFM is used to refer to monitoring with a machine, which results in those heart rate strips. Monitoring simply by doptone is called intermittent auscultation in the medical literature and is generally abbreviated IA.

You can ask if your midwive can turn the sound on the doptone down or otherwise try to make it less noticeable to you, if it is a concern. I absolutely would not skip it.

[stephbrownthinks]

I barely even noticed the heart rate monitoring. I only remember the midwife checking it once, I was in the tub and pushing and I think she had headphones? I didn't find it invasive at all. I didn't have to get into a certain position or do anything "special" and it only lasted for maybe a minute.