Electronic fetal heart rate monitoring: why the dilemma?

As medical technology becomes more and more complex, both the benefits and risks increase. Perhaps we have misled ourselves and, unwittingly, our patients into expecting the perfect outcome by complication-free care. As we learn more about the pathophysiology of disease it becomes apparent that our expectations are unrealistic. In addition, as clinicians we have become more sophisticated about the utility of clinical testing. We have learned that the predictive value of a test is related to its sensitivity and specificity, and to the prevalence of the disease in the population being tested. We have also seen that the prevalence of intrapartum asphyxia is low and the prevalence of hypoxic-ischemic encephalopathy perhaps even lower. Therefore, the positive predictive value for an ominous fetal heart rate pattern in a low-risk patient to be indicative of fetal asphyxia is probably quite low, even if confirmed by a low fetal scalp pH. In practical terms, a number of emergency cesarean sections will be done unnecessarily, at least in retrospect. Collectively, society is concerned about the high and rising cesarean section rate, although the individual patient "knows" that the "brain-damaged" infant can be prevented by intrapartum fetal heart rate monitoring and emergency section. The reality is that from the best studies available it has yet to be demonstrated that routine EFM in the low-risk patient has provided a benefit. We continue to imply a benefit by its widespread use and wonder why the dilemma. Should our patients expect less? Should the lawyers expect less? Even our experts can not agree. Good practice is our goal. We can accept nothing less.(ABSTRACT TRUNCATED AT 250 WORDS)