The Role of Interpretation – ACOG Refines Fetal Heart Rate Monitoring Guidelines

by Jun 24, 2009Hospital birth, Infant Outcomes8 comments

Photo credit: http://healthmad.com/health/fetal-monitoring/

Photo credit: http://healthmad.com/health/fetal-monitoring/

I remember when I was pregnant with my first.  The CNM I hired worked at multiple hospitals, so my husband and I toured each one to get a feel for each hospital’s standard policies and procedures.  A few people I knew questioned why we were bothering doing this since, aren’t all hospitals the same?  While I was expecting some differences, I was really surprised with what I found.

The standard procedures of the three hospitals we toured varied greatly – everything from the use of telemetry (wireless fetal) monitoring to how much bonding time a mom and baby were permitted before baby was whisked away for mandatory hospital procedures to where babies slept at night and whether babies were routinely given sugar water, formula or a pacifier.

I came away realizing how important it is to carefully screen which hospital you chose as well as your OB/midwife and the L&D nurse who will be caring for you during your stay at the hospital.

This June 22, 2009 press release illustrates ACOG’s (The American College of Obstetricians and Gynecologists’) efforts to help standardize the care women receive from OBs.  Specifically, they wish to stabilize the variability in fetal heart rate interpretations which could considerably impact the frequency of the “fetal distress” diagnosis.

EFM refers to external fetal monitoring which most women know as the belt laboring women wear that measures the baby’s heart rate and is connected to a machine which produces a strip of the baby’s heart rate as well as mom’s contractions.

I found these quotes of particular interest (emphasis is mine).

“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”

“Our goal with the ACOG guidelines was to define existing terminology and narrow definitions and categories so that everyone is on the same page,” says Dr. Macones. One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.

A meta-analysis study shows that although EFM reduced the risk of neonatal seizures, there is still an unrealistic expectation that a nonreassuring FHR can predict the risk of a baby being born with cerebral palsy. The false-positive rate of EFM for predicting cerebral palsy is greater than 99%. This means that out of 1,000 fetuses with nonreassuring readings, only one or two will actually develop cerebral palsy. The guidelines state that women in labor who have high-risk conditions such as preeclampsia, type 1 diabetes, or suspected fetal growth restriction should be monitored continuously during labor.

Note that VBAC is not listed under “high-risk conditions” that “should be monitored continuously during labor.”  Also, with a 99% false positive rate for cerebral palsy, I wonder about the rate of uterine rupture false positives.

Here is the link, ACOG Refines Fetal Heart Rate Monitoring Guidelines.

What do you think?
Leave a comment.

What do you think? Leave a comment.


  1. I noticed that ACOG recently added i their bulletin “prior caesarean” to their list of “conditions” that needs continuous monitoring, although I’ve heard there’s no research supporting their guideline. The link to the 2009 document you included here has expired. If ACOG has recommended continuous EFM, it makes sense that hospitals would have a policy on it. Unfortunately, the hospital I’m planning to deliver at is telling me I must have EFM, and that precludes me having access to laboring in the water. They don’t have access to a mobile monitor. I guess I’d like to know if I have a legal right to decline EFM and still obtain treatment at the hospital. It is a university hospital. I’d also like to know how to best advocate for myself in a way that’s effective without ticking everyone off. Thank you.

    • Hi!

      First, yes, you have the legal right to decline EFM and they still have to treat you. Ideally, you will express what you want and they will respect that. (Check out ACOG’s Committee Opinion on informed refusal for more.)

      When exercising your right to informed refusal, you can start with something like, “I hear what you are saying and I still decline/do not consent.”

      If they insist that this is hospital policy, you can say, “I’d like to see that policy in writing and I’d like you to notify the legal department that you are going to force me to have an intervention that I have formally declined.”

      You can also encourage the nurse to document your non-consent by saying, “Nurse, please document, I do not consent.”

      If they still persist, you can request the patient advocate.

      Last resort would be reaching out to organizations like the National Advocates for Pregnant Women or Improving Birth.

      While you have the legal right to decline anything, I recommend discussing this with your provider as soon as possible. You want to get an idea of where they stand before you are in the throws of labor.

      Some providers will respect your right to informed refusal, others won’t and you won’t know what you are dealing with until you are in the moment. What is the reputation of the hospital? Do you know any doulas that can give you the inside scoop?

      I hope this helps!



  2. Do you have any advice on how to fight for manual/intermittent monitoring during a vbac? From what I understand vbac is not a condition that requires continuous monitoring yet all hospital procedures require continuous monitoring for vbacs.

    • Erica,

      Yes, you can advocate to have intermittent monitoring, but it’s important to understand the risks and benefits of that decision. Yes, there are false positives with continuous external fetal monitoring. But, if you have a uterine rupture, the monitoring can make a difference in terms of outcomes. So there is a lot to consider here.

      I discuss monitoring in VBACs in great depth as well as how to advocate for yourself in my online workshop, “The Truth About VBAC for Families“. If you want to learn more, that is the fastest way to get to up speed on all things uterine rupture, VBAC, repeat cesarean, home birth, hospital birth, and your legal rights. And if you sign up with two friends, you can save 50% off of registration.

      Hope this helps!


  3. Increíble Web .Sigue adelante con este excelente trabajo.
    Presenta un punto de vista realmente excelente sobre el tema y los mensajes son muy acertados.
    Simplemente decir que estoy feliz por haber visto esta Página web
    Seguramente tienes el mejor sitio de internet sobre el tema.

    Muchas gracias 🙂

  4. Thank you! Oh yes I know about placenta accreta. I am in the situation where my first c-section was medically necessary (severe pre-eclampsia/beginning HELLP) but the hospital/OB was very anti-vbac, so I had to change both to find a vbac friendly environment, but my husband picked up from the previous environment that vbac’s are dangerous and my having to change doctors and hospital makes him nervous. Outlining the risks of other things that can go wrong during any vaginal delivery makes uterine rupture not stand out so much as the worst thing in the world or a reason not to try for a vbac.
    I do have the NIH statement on hand, and also the Department of heath and human services evidence report which gathered the background evidence for the NIH conference – actually I didn’t see it on your resource website, so here that is as well (though I’m sure it’s in your stash somewhere!). I haven’t made it through the whole report yet (400 pages) but what I have read is really interesting.


    Thank you again!

  5. Very interesting! Thank you for this incredibly resource heavy website. For that, here’s the updated link to the ACOG publication:


    I thought I had found an article here about the rate of uterine rupture as compared to other obstetrical emergencies in tabular form to compare the rate and maternal and neonetal risk of each, but I am unable to find it now. Do you have that information?

    Thank you!

    • Hi Jenn!

      Thanks for the link update. ACOG updated their website a couple years ago so many of the older links I provide here no longer work.

      I believe the chart you are looking for can be found in an article written by two OBs protesting a VBAC ban at their local rural hospital.

      I’m sure you already know, but for the benefit of future readers, I want to point out that the incidence of obstetrical complications does not necessarily reflect the rates of infant or maternal morbidity/mortality. Take placeta accreta which I talk about quite a bit. The risk is very low for a first time mom (less than 0.5%), but increases with each subsequent cesarean. The risk of maternal mortality for accreta has been reported around 7-8%. That is significant.

      If you want the latest and greatest information on VBAC, I recommend you check out the Guise 2010 Evidence Report, the National Institutes of Health’s VBAC Statement, as well as the many presentation videos from the 2010 NIH VBAC Conference. You can access all of these resources here.




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Jen Kamel

As an internationally recognized consumer advocate and Founder of VBAC Facts®, Jen helps perinatal professionals, and cesarean parents, achieve clarity on vaginal birth after cesarean (VBAC) through her educational courses for parents, online membership for professionals, continuing education trainings, and consulting services. She speaks at conferences across the US, presents Grand Rounds at hospitals, advises on midwifery laws and rules that limit VBAC access, educates legislators and policy makers, and serves as an expert witness and consultant in legal proceedings. She envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support, so they can plan the birth of their choosing in the setting they desire.

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