MIDIRS Essence > March 2010 > Midwifery News

Reassurance or commercial insurance?

Originally posted on Mar 2010

I came across a short article in the BMJ recently, titled ‘The dangers of listening to the fetal heart at home’ (Chakladar & Adams 2009). As the title itself was interesting in its negativity, I felt it incumbent upon me to investigate further.

The authors note that ‘measuring’ the fetal heart rate in pregnancy and in labour, as part of the observation for monitoring the health of the fetus, requires training and skill if it is to be undertaken accurately. They note that these same observations can now be achieved by parents as they can buy a fetal heart rate monitor over the counter. The authors then recount a case study of a 34 year old woman who, having noticed a reduction in fetal movements, had used a fetal heart rate monitor and was reassured to hear what she assumed was the baby’s heartbeat. Unfortunately, the baby died in utero and it was thought that what the mother had heard was more probably her own heartbeat. A second, similar episode was also described in which the baby did not die but suffered from serious neurological morbidity.

The authors investigated the promotion of these monitors and found that they were quite widely available, but that there was a significant lack of appropriate advice about their reliability overall. It also appeared that the information was linked more to the perception that the use of these would do no physical harm (to the baby) rather than any limitations about their efficiency to detect problems with the baby’s well-being that needed prompt medical referral.

By chance, I also recently came across a paper written in 1997 (Armfelt 1997) where the purchase of baby alarms, baby monitors and infant thermometers for use by parents without sufficient background information or resuscitation skills was questioned by health visitors. The paper explores the exploitation of parents and the need for better safety legislation to regulate and monitor the use and promotion of commercial products and, while some time has elapsed since the publication of that paper, I have found very little evidence that anything much has changed with regard to the professional advice/consumer promotion gap.

Referring back to the case study presented, the change in fetal movements was the first concern noted by the mother and, while the authors acknowledge that there is no direct link to the use of the home monitoring system and the outcome, there is a link to fetal movements and fetal well-being. They include reference to the use of observation of fetal movements and their questionable efficacy (Mangesi & Hofmeyer 2007) but comment that in their unit it is usual for women to count fetal movements as part of their assessment of fetal well-being. It would appear then that advice is given to women about contacting a health care professional where the pattern of movements for their baby changes, and especially diminishes; then the best support any health care service can and does offer is for the health care professionals to investigate and ensure that all is well and if it is not, to be able to take prompt action (Heazell & Froen 2008).

Dependency on any single observation is also questionable and the authors raise concern about an increase in false negative findings. Women can become over-anxious if they are unable to locate a heart rate due to inexperience with the device, which then puts pressure on GP and midwifery services where there is not an actual problem. After this quite competent, albeit brief, exploration of the issues, it is disappointing that the authors end with a fairly didactic sentence where they state that there is a need for the obstetric services to educate women about the risks of these devices, as well as to present clear guidance on when to seek medical review. I think this is where I part company with the ethos of this piece. It would appear that these monitors are freely available, as are an uncountable number of other products, therapies etc, which parents buy in an attempt to help make pregnancy, labour and child care safer and easier. While there might be some cracks in the NHS and even in the independent health care services for women’s care in pregnancy, labour and afterwards, I would argue that very few women would not be given the advice about what to look for to ensure their baby’s well-being in utero, without the need for a fetal heart monitor. I think the onus is more on the manufacturers of these products to ensure the information about the limitations of these is very clear; perhaps the advice given to women, where they choose to purchase them, should be to inform their health care providers that they are using one. This then at least gives the health carer an opportunity to explore the appropriate use of these with the parents.

At the same time, being a midwife who grew up, in midwifery terms, using the well trusted pinnard, I really support the use of current technology that can share the very special sounds of the fetal heart with the parents. So, yes, I can see there are potential dangers to the use of fetal monitoring at home where this is undertaken without appropriate support, but I can also see the attraction. I am surprised that they appear to be so popular when a midwife, GP or consultant unit will provide the same thing, but time has moved on and I think the key concept is communication, so that free ‘commercial’ choice is also supported by informed choice provided by professional expertise.

References

Armfelt C (1997). Wise buy? Health Visitor 70(11):413.

Chakladar A, Adams H (2009). The dangers of listening to the fetal heart at home BMJ 339(7730):1112-3.

Heazell AEP, Froen JF (2008). Methods of fetal movement counting and the detection of fetal compromise. Journal of Obstetrics and Gynaecology 28(2):147-54.

Mangesi L, Hofmeyer GJ (2007). Fetal movement counting for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews, issue 1.

Dr Sally Marchant | MIDIRS Midwifery Digest Editor | MIDIRS | Photo Credit: Image Source

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