I just had my second c section. It was an emergency c section after a trial of labor. I’m struggling to make peace with it because the reason was ongoing long late heartrate decels. It was a midwife led birth at the hospital with the best VBAC rate near me. I felt like I did everything “right” and still ended up being ran down the hall when my baby’s heartrate didn’t recover after 4 minutes. I’ve been trying to get the strips for 3 months and still haven’t seen them myself, but I’ve heard the decels were in the 30s/40s. The doctor ended up making a mistake in my surgery that caused an injury to me because it was done so quickly and I ended up on the table for 3 hours. I *think* the c section was necessary but I struggle to know for sure. A lot of “crunchy” moms have told me I should have done this or that to avoid it and that the doctor could have made the wrong call. But at the same time I felt like everyone in the room let it go on for as long as possible until it got truly concerning. I don’t really know if I have a question…I guess just sharing my experience of being on one side of this conversation. It is confusing and frustrating!
I’m so sorry that happened to you. FWIW, that doesn’t sound like an unnecessary C-section AT. ALL. It sounds like you DID do everything right. At some point, a baby with FHTs too low for too long will be compromised. I’m glad your baby was ok (sorry about the complicated surgery, though!) and I would definitely not listen to the crunchy moms telling you this was preventable. While this outcome is obviously not what you wanted, it seems like you put yourself in a good position to have a VBAC but it just didn’t work out. Especially with a trial of labor after cesarean, the risk of uterine rupture or just bad placentation (leading to worse oxygenation of baby) is real. Doesn’t mean it’s your fault or anyone else’s! I hope you recovery ok emotionally and physically.
Thank you so much for this thoughtful reply Ann 🤍 I did have a follow up with the doctor and asked her a million questions and she said she truly felt his life was at risk and that was her priority. It stinks I was injured in the process but obviously I’d do anything for my babies to be ok. Thankfully he didn’t need NICU time and bounced back pretty quick after a lower initial apgar score. I’ve been fascinated with this topic though since having this experience! I enjoyed reading your piece!
Loved this whole article apart from the very last thing about your friend! As a pregnant person this all read as very balanced and measured and then WHAM oh actually continuous monitoring stopped my friend’s kid from dying?! Thought I would share as I felt strongly that was not a great ending for pregnant people reading this if part of the idea was to get people to consider IA and midwife led care etc
I can see where you’re coming from! I think my goal there was to kind of make the point that, while the evidence does NOT favor cEFM above IA on whole, there are clearly individual cases where it can make a difference. The truth is that bad things can/do happen, and it’s not always because medical providers “messed up.” In fact, sometimes these technologies help. But I see your point. Hmm. I’ll think about changing it ;)
This brought up so many emotions for me. I’m an RN and only did a short stint on L&D before quitting. I loved and hated it.
The c section rates varied tremendously by provider. There was one doctor that was notorious about diagnosing every labor as failure to progress or fetal distress.
Not a single provider supported IA. Perfect IA candidates would come in and request IA, but I never saw a single one successfully get it; they were always talked into cEFM.
Nurses or doctors who waited and did more interventions prior to c sections for strips on the gray zone were ruthlessly gossiped about. They still gossiped about a bad outcome that happened 7 years prior; they fully blamed the doctor.
They were all for position changes during labor until it came to hands and knees. The nurses and doctors gave lip service to pushing in various positions until it came to actual pushing; then your options were either directly on your back or slightly tilted to the side while still on your back.
I chose home birth for both my births, which fully made me a black sheep. Multiple times, I received comments from more senior nurses about how I wouldn’t be choosing home birth if I’d seen what they’d seen.
I just can’t imagine going into a hospital like the one I worked in and taking the gamble of which nurses and doctor would be yours. It’s wild how differently almost identical labors can go depending on who the nurses and providers are.
It is absolutely wild. I have been really blessed as a CNM to attend births in hospitals very much NOT like the one you are describing. But I also worked as an RN in a hospital where a lot of unnecessary C-sections were done. It used to make me so angry and keep me up at night. It was good motivation to become a CNM. Maybe you should become one too! Seems like you'd be good at it :)
That means a lot! Becoming a CNM was my original goal, but that unit chewed up that desire and spit it out. Maybe once my kids are older I’ll revisit CNM schooling:’)
I wonder if the peaking between between 9 pm and 3 am may have anything to do with night shift nurses often being less experienced and more “jumpy” with strips that aren’t cat 1 or cat 2 for simple variable decels or lacking accelerations. In my experience, night shift was full of newer nurses who were very quick to make phone calls and request the doctor at the bedside. The doctors at our hospital were also less trained on reading strips than nurses; they were often talked down during the day by senior nurses when a strip went into the gray zone. At night, the newer nurses just fed into the doctors’ anxieties over strips that weren’t perfect.
I worked nights and there was definitely a push to get C-sections done between 7p-10p! I'm a little surprised this study showed them happening at 3 am. In my experience NO ONE wanted to do the 3 am C-section, even if it was really needed. And EVERYONE wanted to do the 8 am or 7 pm C-section even if it was NOT needed.
This was cool to read! I just delivered my second baby recently and was induced for risk factors (had pre-e with my first and had white coat hypertension / well managed stage I cHTN in my second pregnancy). Anyway, there were some delays with the induction and I actually kind of enjoyed watching the tracing and being able to snoop on the tracing in other rooms, just looking at the patterns from an uneducated perspective I was mesmerized by it. I did have IA in my birth preferences if I had gone into spontaneous labor but knew it was very likely to get continuous instead. Both my babies did not like staying on the monitor, and I also moved positions a lot, so the nurses had to come reposition the discs super frequently. The main frustration I had in this labor was that even with the mobile setup (kind of like wearing a Walkman ?), with a pulse ox, IV, and fetal monitoring I felt like such a tangle of cords it was hard to really embrace freedom of mobility. And I used nitrous for pain management so I had a mask with another type of cord, plus a TENS unit so I was just hooked up everywhere. I can see why a low risk spontaneous labor could be a bit less inhibited at a birth center. But ultimately I’m grateful to the midwifery led hospital team where I delivered — with their support and a great doula too, I had a fast and physically active birth and delivered on hands and knees in the bed without epidural. And all this after a successful ECV to turn my breech babe around!
I just recently delivered my first and had a very similar experience. I think without the nurse continuously re-working the monitoring and having me position to optimize the monitor I could have done it without the epidural that I ended up getting around transition! Maybe next time. I’m still pretty happy with how the birth went overall!
Yay! Glad to hear your team helped you avoid a C-section in spite of some risk factors/additional medical needs. Sounds like you got very good, evidence-based care overall, even if the cords and cables got in the way. I agree that this is hard: I am frequently hanging with a mom in labor and it feels like I spend have the time untangling her cords so she can do various positions. So I take every opportunity I can to say "does she really need this cord?" But sometimes, the answer is "yes, she does." So, we do what we can, just like your team did.
I started in a birth center with baby 4 and was transferred for decelerations (they were using IA) and I got so freaked out for the baby and destroyed by the unbearable back labor that I actually did say at one point that I wanted a c-section... but thankfully everyone ignored me lol. The midwife had me get into the position that was easiest on the baby and she was born an hour after we got to the hospital (she was wrapped up several times in her cord like a veiny lil burrito, but was perfectly fine!) So thankful for the very chill midwife at that hospital that day!
Aw, that's a great story (well, maybe not for you. I'm sure it was scary!) But I'm glad they did everything they could to correct the heart tones. With a fourth baby, it feels like it should be easy, but I guess labor does what labor wants!
With my second, I was induced, and the cord was wrapped around my little guy’s neck, so when they would increase my pitocin, his heart rate would go down. It worsened as labor progressed. After I got the epidural, a team of nurses would have to flip my body every 45 minutes to get his heart rate to come back up. It was my second delivery with the same group of doctors, and the doctor felt confident that because the baby’s heart rate was recovering, and because I had a vaginal birth the first time I could deliver vaginally (and I was able to) but having a team of nurses come in to flip you over every hour and listening to your baby’s heart rate plummet for several hours is truly awful!!
I had a low risk, spontaneous labour with IA with my now-toddler, and ended up transferring due to I believe late decels (baby's heart refusing to return to baseline in a timely manner post-contraction). I avoided a caesarean due to position changes supported by the midwife, but my labour stalled so I ended up with cEFM including an internal monitor, augmentation, an epidural (my choice due to augmentation), and 18 hours after the initial decels, forceps. Baby born healthy in terms of hypoxic injury but subsequently developed an infection which meant we stayed in hospital together for a week. I feel very conflicted about it- I wouldn't want potentially serious information ignored, so clearly I feel they did the right thing in transferring, but the consequences feel like on balance I had a lot of adverse issues which probably were made more likely by the interventions I had. It's such an interesting topic and I spend a lot of time mulling over what I would do if the same thing happened again, especially as I am now 6.5 months pregnant with #2! Probably try to avoid the epidural I think to reduce forceps risk, but it was a tough call. I was 7 cm at transfer so a good way through labour!
At the end of the day, I'm glad you didn't ignore the concerns about the decels with IA, and transferred to the hospital. Even if it didn't work out exactly the way you wanted, late decels that are ignored can definitely compromise a baby, and because they knew, it sounds like they were able to do things that ultimately got your baby out quicker (augmentation, forceps). I had a first birth a lot like yours, and I also spent a lot of time feeling bad about it. But then my 2nd and 3rd were much easier. Hope that happens for you too!
Thank you- me too! I am almost afraid to be too hopeful in case I'm one of the people who has the opposite experience (trickier second labour) but I hope not! I appreciate your content on everything.
Probably important context is that I'm in the UK where I was able to labour (and will again, all being well) at an 'alongside midwifery unit' which is essentially a ward within maternity which is run as a birth centre, but where I can and did transfer to labour ward where the obstetricians, anaesthetists etc are based within very few minutes. It always feels like a good set up for precisely this reason and I'm intrigued it seems less common in the US, as it seems to massively derisk most scenarios!
Yes, unfortunately, we do not have too many midwifery run units like that. There are some freestanding birth centers, but most are not alongside hospitals. My guess is that intermittent auscultation is easier to come by in the UK. But I could be wrong!
UGh, I am sorry to hear this. It really needs to be considered more normal, especially because it is EVIDENCE-BASED! Personally, I am SO excited when a patient mentions to me that she wants this. Because, a. It tells me that she's done her homework, and b. I can now tell staff at the hospital "look, this is what SHE wants." Otherwise, I get a lot of nurses giving me the side eye, annoyed because I'm making more work for them when I order IA instead of cEFM.
I had a c-section due to fetal intolerance of labor—my daughter wasn’t receiving enough oxygenated blood from the placenta. Which really freaked me out when the doctor casually said “you’ve seen enough shows to know what a flatline is.” Then he said it was up to me, but i remember panicking thinking my baby was gonna die. Now part of me wants to try for a VBAC next time but seeing how everything goes against you at a hospital birth I don’t even want to get my hopes up.
Yeah, it's hard to know what the best choice is. I am overall very pro-VBAC and we do a lot of them :) But really bad FHTs like that (absent variability) are overall pretty rare, and it's not necessarily going to repeat itself. Who knows! Best of luck to you and hope it goes well whatever you choose.
This brought up a lot for me. I gave birth at 46, and when the fetal monitoring became concerning, I agreed to a C-section because I was terrified of taking any risk with my daughter’s safety.
Reading this now makes me wonder whether the monitoring may have contributed to the urgency of that decision. At the same time, my age made the choice feel even more complicated. When you have already been told that your pregnancy is higher risk, it becomes very difficult to know where informed consent ends and fear begins.
I’m so grateful my daughter arrived safely, but I still carry questions about whether the C-section was truly necessary. I appreciate the nuance of this piece because it leaves room for both realities: fetal monitoring can save lives, and it can also lead to interventions that mothers may spend years trying to understand.
This is an awesome article thank you for writing. I’ve worked as a labor and delivery nurse in a small Canadian rural hospital, a tertiary center in Canada and now a huge level 4 l&D in the USA. The differences and practices are SO different. In Canada we had to prove why we needed CEFM. Now where I work you can kick and scream and IA never happens 🙃
That's really sad to hear! I wish IA were not so looked down upon in the U.S. Do you find the nurses you work with are resistant to it? Or the doctors just don't want to order it?
Yeah, good question. I didn't really talk about that. It is called a fetal scalp electrode. These are placed often when fetal heart tones are difficult to trace. I dislike them because I think it's a small risk to the baby. You are literally screwing a wire into their head. But yes, sometimes they are necessary--If you really can't get heart tones any other way and you are worried about the baby.
Phenomenal article. I’ve always wondered why so many of my friends (mostly Latinas) ended up with a c section and it seems like there’s something of prejudice at work there, based on some of the info you shared here?
Also, every time I read one of your articles, I realize that my hospital births are likely not the norm and that I won the OB/GYN lottery. My doc is so incredibly hands off—even when I was diagnosed with GD, he didn’t offer me insulin, ever, and pretty much left me alone. His answer to everything was, “let’s just keep an eye on it, it’s probably not a big deal.” He didn’t push interventions, didn’t even suggest them. I had two successful vaginal deliveries, both without an epidural (which was my choice, but I add it because my choice was very well supported). I also had incredible nurses during my second delivery when I had to be induced. Just really grateful for our birthing team.
Really appreciate this article and the tools you offer. I labored for 60 hours (partially at home and partially in the hospital) with my first daughter and while I was able to have a vaginal birth i also did end up with an epidural and pitocin (neither of which I wanted). I’m mentioning this because my gut feeling at the time and later on processing the labor was that the fetal monitor was one of the main reasons I got stuck for so long and ended up making the choice to take the epidural. For me at least the natural thing I wanted to do was to be on all fours through my contractions and the monitor forced me to be on my back. I felt strongly then and in retrospect that if I’d been able to move and follow my body’s cues I wouldn’t have needed the epidural and things would have progressed more quickly. This is all to say that in my (limited) experience the monitor affects other aspects of birth experience than c sections as well. I’m curious if you have any thoughts on that?
This is what I mean by “we need to improve this technology.” It really does force or encourage back lying in labor, which is THE. WORST. I am lucky to work with nurses who believe in position change and take the time to find fetal heart tones in any position. But I’m not gonna lie: it’s HARDER to find a baby’s FHTs when a mom is in hands and knees.
I do think limited mobility influences the need for epidural, as movement is also one of the best ways of coping with labor pain. That being said, a 60 h labor is pretty long! I had a 48 h labor with my first and I too ended up with Pitocin and an epidural that I wasn’t planning on. So at some point, I think we also have to acknowledge that first labors are just HARD. I wrote about that a bit here: https://annledbetter.substack.com/p/are-humans-bad-at-birth?r=8c5pl
Yes for sure! Definitely a combination of things. I’ve got #2 on the way now so fingers crossed it will be easier! Thanks for your thoughtful reply. I enjoyed the second article as well:)
I just had my second c section. It was an emergency c section after a trial of labor. I’m struggling to make peace with it because the reason was ongoing long late heartrate decels. It was a midwife led birth at the hospital with the best VBAC rate near me. I felt like I did everything “right” and still ended up being ran down the hall when my baby’s heartrate didn’t recover after 4 minutes. I’ve been trying to get the strips for 3 months and still haven’t seen them myself, but I’ve heard the decels were in the 30s/40s. The doctor ended up making a mistake in my surgery that caused an injury to me because it was done so quickly and I ended up on the table for 3 hours. I *think* the c section was necessary but I struggle to know for sure. A lot of “crunchy” moms have told me I should have done this or that to avoid it and that the doctor could have made the wrong call. But at the same time I felt like everyone in the room let it go on for as long as possible until it got truly concerning. I don’t really know if I have a question…I guess just sharing my experience of being on one side of this conversation. It is confusing and frustrating!
I’m so sorry that happened to you. FWIW, that doesn’t sound like an unnecessary C-section AT. ALL. It sounds like you DID do everything right. At some point, a baby with FHTs too low for too long will be compromised. I’m glad your baby was ok (sorry about the complicated surgery, though!) and I would definitely not listen to the crunchy moms telling you this was preventable. While this outcome is obviously not what you wanted, it seems like you put yourself in a good position to have a VBAC but it just didn’t work out. Especially with a trial of labor after cesarean, the risk of uterine rupture or just bad placentation (leading to worse oxygenation of baby) is real. Doesn’t mean it’s your fault or anyone else’s! I hope you recovery ok emotionally and physically.
Thank you so much for this thoughtful reply Ann 🤍 I did have a follow up with the doctor and asked her a million questions and she said she truly felt his life was at risk and that was her priority. It stinks I was injured in the process but obviously I’d do anything for my babies to be ok. Thankfully he didn’t need NICU time and bounced back pretty quick after a lower initial apgar score. I’ve been fascinated with this topic though since having this experience! I enjoyed reading your piece!
Thank you for reading :)
Loved this whole article apart from the very last thing about your friend! As a pregnant person this all read as very balanced and measured and then WHAM oh actually continuous monitoring stopped my friend’s kid from dying?! Thought I would share as I felt strongly that was not a great ending for pregnant people reading this if part of the idea was to get people to consider IA and midwife led care etc
I can see where you’re coming from! I think my goal there was to kind of make the point that, while the evidence does NOT favor cEFM above IA on whole, there are clearly individual cases where it can make a difference. The truth is that bad things can/do happen, and it’s not always because medical providers “messed up.” In fact, sometimes these technologies help. But I see your point. Hmm. I’ll think about changing it ;)
Yep. It hit me exactly the same way as a someone who’s currently pregnant. Great article with lots of helpful information though!
This brought up so many emotions for me. I’m an RN and only did a short stint on L&D before quitting. I loved and hated it.
The c section rates varied tremendously by provider. There was one doctor that was notorious about diagnosing every labor as failure to progress or fetal distress.
Not a single provider supported IA. Perfect IA candidates would come in and request IA, but I never saw a single one successfully get it; they were always talked into cEFM.
Nurses or doctors who waited and did more interventions prior to c sections for strips on the gray zone were ruthlessly gossiped about. They still gossiped about a bad outcome that happened 7 years prior; they fully blamed the doctor.
They were all for position changes during labor until it came to hands and knees. The nurses and doctors gave lip service to pushing in various positions until it came to actual pushing; then your options were either directly on your back or slightly tilted to the side while still on your back.
I chose home birth for both my births, which fully made me a black sheep. Multiple times, I received comments from more senior nurses about how I wouldn’t be choosing home birth if I’d seen what they’d seen.
I just can’t imagine going into a hospital like the one I worked in and taking the gamble of which nurses and doctor would be yours. It’s wild how differently almost identical labors can go depending on who the nurses and providers are.
It is absolutely wild. I have been really blessed as a CNM to attend births in hospitals very much NOT like the one you are describing. But I also worked as an RN in a hospital where a lot of unnecessary C-sections were done. It used to make me so angry and keep me up at night. It was good motivation to become a CNM. Maybe you should become one too! Seems like you'd be good at it :)
That means a lot! Becoming a CNM was my original goal, but that unit chewed up that desire and spit it out. Maybe once my kids are older I’ll revisit CNM schooling:’)
I wonder if the peaking between between 9 pm and 3 am may have anything to do with night shift nurses often being less experienced and more “jumpy” with strips that aren’t cat 1 or cat 2 for simple variable decels or lacking accelerations. In my experience, night shift was full of newer nurses who were very quick to make phone calls and request the doctor at the bedside. The doctors at our hospital were also less trained on reading strips than nurses; they were often talked down during the day by senior nurses when a strip went into the gray zone. At night, the newer nurses just fed into the doctors’ anxieties over strips that weren’t perfect.
I worked nights and there was definitely a push to get C-sections done between 7p-10p! I'm a little surprised this study showed them happening at 3 am. In my experience NO ONE wanted to do the 3 am C-section, even if it was really needed. And EVERYONE wanted to do the 8 am or 7 pm C-section even if it was NOT needed.
This was cool to read! I just delivered my second baby recently and was induced for risk factors (had pre-e with my first and had white coat hypertension / well managed stage I cHTN in my second pregnancy). Anyway, there were some delays with the induction and I actually kind of enjoyed watching the tracing and being able to snoop on the tracing in other rooms, just looking at the patterns from an uneducated perspective I was mesmerized by it. I did have IA in my birth preferences if I had gone into spontaneous labor but knew it was very likely to get continuous instead. Both my babies did not like staying on the monitor, and I also moved positions a lot, so the nurses had to come reposition the discs super frequently. The main frustration I had in this labor was that even with the mobile setup (kind of like wearing a Walkman ?), with a pulse ox, IV, and fetal monitoring I felt like such a tangle of cords it was hard to really embrace freedom of mobility. And I used nitrous for pain management so I had a mask with another type of cord, plus a TENS unit so I was just hooked up everywhere. I can see why a low risk spontaneous labor could be a bit less inhibited at a birth center. But ultimately I’m grateful to the midwifery led hospital team where I delivered — with their support and a great doula too, I had a fast and physically active birth and delivered on hands and knees in the bed without epidural. And all this after a successful ECV to turn my breech babe around!
I just recently delivered my first and had a very similar experience. I think without the nurse continuously re-working the monitoring and having me position to optimize the monitor I could have done it without the epidural that I ended up getting around transition! Maybe next time. I’m still pretty happy with how the birth went overall!
Yay! Glad to hear your team helped you avoid a C-section in spite of some risk factors/additional medical needs. Sounds like you got very good, evidence-based care overall, even if the cords and cables got in the way. I agree that this is hard: I am frequently hanging with a mom in labor and it feels like I spend have the time untangling her cords so she can do various positions. So I take every opportunity I can to say "does she really need this cord?" But sometimes, the answer is "yes, she does." So, we do what we can, just like your team did.
I started in a birth center with baby 4 and was transferred for decelerations (they were using IA) and I got so freaked out for the baby and destroyed by the unbearable back labor that I actually did say at one point that I wanted a c-section... but thankfully everyone ignored me lol. The midwife had me get into the position that was easiest on the baby and she was born an hour after we got to the hospital (she was wrapped up several times in her cord like a veiny lil burrito, but was perfectly fine!) So thankful for the very chill midwife at that hospital that day!
Aw, that's a great story (well, maybe not for you. I'm sure it was scary!) But I'm glad they did everything they could to correct the heart tones. With a fourth baby, it feels like it should be easy, but I guess labor does what labor wants!
With my second, I was induced, and the cord was wrapped around my little guy’s neck, so when they would increase my pitocin, his heart rate would go down. It worsened as labor progressed. After I got the epidural, a team of nurses would have to flip my body every 45 minutes to get his heart rate to come back up. It was my second delivery with the same group of doctors, and the doctor felt confident that because the baby’s heart rate was recovering, and because I had a vaginal birth the first time I could deliver vaginally (and I was able to) but having a team of nurses come in to flip you over every hour and listening to your baby’s heart rate plummet for several hours is truly awful!!
Yeah, I know that can be scary! But I'm glad they did it, and it sounds like they were able to help you avoid a C-section, so that's good!
I had a low risk, spontaneous labour with IA with my now-toddler, and ended up transferring due to I believe late decels (baby's heart refusing to return to baseline in a timely manner post-contraction). I avoided a caesarean due to position changes supported by the midwife, but my labour stalled so I ended up with cEFM including an internal monitor, augmentation, an epidural (my choice due to augmentation), and 18 hours after the initial decels, forceps. Baby born healthy in terms of hypoxic injury but subsequently developed an infection which meant we stayed in hospital together for a week. I feel very conflicted about it- I wouldn't want potentially serious information ignored, so clearly I feel they did the right thing in transferring, but the consequences feel like on balance I had a lot of adverse issues which probably were made more likely by the interventions I had. It's such an interesting topic and I spend a lot of time mulling over what I would do if the same thing happened again, especially as I am now 6.5 months pregnant with #2! Probably try to avoid the epidural I think to reduce forceps risk, but it was a tough call. I was 7 cm at transfer so a good way through labour!
Sorry you had such a rough go of it. On the bright side, your body has now done this once before and chances are labor will be MUCH faster the second time (wrote about that a little here: https://annledbetter.substack.com/p/are-humans-bad-at-birth?r=8c5pl
At the end of the day, I'm glad you didn't ignore the concerns about the decels with IA, and transferred to the hospital. Even if it didn't work out exactly the way you wanted, late decels that are ignored can definitely compromise a baby, and because they knew, it sounds like they were able to do things that ultimately got your baby out quicker (augmentation, forceps). I had a first birth a lot like yours, and I also spent a lot of time feeling bad about it. But then my 2nd and 3rd were much easier. Hope that happens for you too!
Thank you- me too! I am almost afraid to be too hopeful in case I'm one of the people who has the opposite experience (trickier second labour) but I hope not! I appreciate your content on everything.
Probably important context is that I'm in the UK where I was able to labour (and will again, all being well) at an 'alongside midwifery unit' which is essentially a ward within maternity which is run as a birth centre, but where I can and did transfer to labour ward where the obstetricians, anaesthetists etc are based within very few minutes. It always feels like a good set up for precisely this reason and I'm intrigued it seems less common in the US, as it seems to massively derisk most scenarios!
Yes, unfortunately, we do not have too many midwifery run units like that. There are some freestanding birth centers, but most are not alongside hospitals. My guess is that intermittent auscultation is easier to come by in the UK. But I could be wrong!
Thank you so much! This is so helpful and informative
The phrase "intermittent monitoring" scared the crap out of every health professional I spoke with 🤦♀️
UGh, I am sorry to hear this. It really needs to be considered more normal, especially because it is EVIDENCE-BASED! Personally, I am SO excited when a patient mentions to me that she wants this. Because, a. It tells me that she's done her homework, and b. I can now tell staff at the hospital "look, this is what SHE wants." Otherwise, I get a lot of nurses giving me the side eye, annoyed because I'm making more work for them when I order IA instead of cEFM.
I had a c-section due to fetal intolerance of labor—my daughter wasn’t receiving enough oxygenated blood from the placenta. Which really freaked me out when the doctor casually said “you’ve seen enough shows to know what a flatline is.” Then he said it was up to me, but i remember panicking thinking my baby was gonna die. Now part of me wants to try for a VBAC next time but seeing how everything goes against you at a hospital birth I don’t even want to get my hopes up.
Yeah, it's hard to know what the best choice is. I am overall very pro-VBAC and we do a lot of them :) But really bad FHTs like that (absent variability) are overall pretty rare, and it's not necessarily going to repeat itself. Who knows! Best of luck to you and hope it goes well whatever you choose.
This brought up a lot for me. I gave birth at 46, and when the fetal monitoring became concerning, I agreed to a C-section because I was terrified of taking any risk with my daughter’s safety.
Reading this now makes me wonder whether the monitoring may have contributed to the urgency of that decision. At the same time, my age made the choice feel even more complicated. When you have already been told that your pregnancy is higher risk, it becomes very difficult to know where informed consent ends and fear begins.
I’m so grateful my daughter arrived safely, but I still carry questions about whether the C-section was truly necessary. I appreciate the nuance of this piece because it leaves room for both realities: fetal monitoring can save lives, and it can also lead to interventions that mothers may spend years trying to understand.
I wrote about my birth here: https://theembodimentguide.substack.com/p/i-wanted-to-experience-everything
This is an awesome article thank you for writing. I’ve worked as a labor and delivery nurse in a small Canadian rural hospital, a tertiary center in Canada and now a huge level 4 l&D in the USA. The differences and practices are SO different. In Canada we had to prove why we needed CEFM. Now where I work you can kick and scream and IA never happens 🙃
That's really sad to hear! I wish IA were not so looked down upon in the U.S. Do you find the nurses you work with are resistant to it? Or the doctors just don't want to order it?
It’s the doctors all the way. Some of the nurses at my hospital have never done it and have been there for years.
Maybe your hospital needs some CNMs! IA isn't all that common in our hospital, but it's not all that weird either!
We have them 😳
Maybe you can start an IA riot! Good luck! Honestly if patients put the pressure on that would help too. More moms need to ask for IA!
Can I ask what is this thing they put on the baby head during birth? Is this more accurate to find out how the baby is doing?
Yeah, good question. I didn't really talk about that. It is called a fetal scalp electrode. These are placed often when fetal heart tones are difficult to trace. I dislike them because I think it's a small risk to the baby. You are literally screwing a wire into their head. But yes, sometimes they are necessary--If you really can't get heart tones any other way and you are worried about the baby.
Thank you for this as an expecting mom RN! I’m going to be finding sn old OB textbook and relearning fetal heart tracing I guess!
Here's something a little more recent: https://www.ncbi.nlm.nih.gov/books/NBK546627/
Phenomenal article. I’ve always wondered why so many of my friends (mostly Latinas) ended up with a c section and it seems like there’s something of prejudice at work there, based on some of the info you shared here?
Also, every time I read one of your articles, I realize that my hospital births are likely not the norm and that I won the OB/GYN lottery. My doc is so incredibly hands off—even when I was diagnosed with GD, he didn’t offer me insulin, ever, and pretty much left me alone. His answer to everything was, “let’s just keep an eye on it, it’s probably not a big deal.” He didn’t push interventions, didn’t even suggest them. I had two successful vaginal deliveries, both without an epidural (which was my choice, but I add it because my choice was very well supported). I also had incredible nurses during my second delivery when I had to be induced. Just really grateful for our birthing team.
Hooray! I love to hear when people received good, evidence based care!
Really appreciate this article and the tools you offer. I labored for 60 hours (partially at home and partially in the hospital) with my first daughter and while I was able to have a vaginal birth i also did end up with an epidural and pitocin (neither of which I wanted). I’m mentioning this because my gut feeling at the time and later on processing the labor was that the fetal monitor was one of the main reasons I got stuck for so long and ended up making the choice to take the epidural. For me at least the natural thing I wanted to do was to be on all fours through my contractions and the monitor forced me to be on my back. I felt strongly then and in retrospect that if I’d been able to move and follow my body’s cues I wouldn’t have needed the epidural and things would have progressed more quickly. This is all to say that in my (limited) experience the monitor affects other aspects of birth experience than c sections as well. I’m curious if you have any thoughts on that?
This is what I mean by “we need to improve this technology.” It really does force or encourage back lying in labor, which is THE. WORST. I am lucky to work with nurses who believe in position change and take the time to find fetal heart tones in any position. But I’m not gonna lie: it’s HARDER to find a baby’s FHTs when a mom is in hands and knees.
I do think limited mobility influences the need for epidural, as movement is also one of the best ways of coping with labor pain. That being said, a 60 h labor is pretty long! I had a 48 h labor with my first and I too ended up with Pitocin and an epidural that I wasn’t planning on. So at some point, I think we also have to acknowledge that first labors are just HARD. I wrote about that a bit here: https://annledbetter.substack.com/p/are-humans-bad-at-birth?r=8c5pl
Yes for sure! Definitely a combination of things. I’ve got #2 on the way now so fingers crossed it will be easier! Thanks for your thoughtful reply. I enjoyed the second article as well:)