I read the recent New York Times piece on Electronic Fetal Monitoring (EFM) driving up C-section rates with a nod of recognition, but also a shake of my head. The article isn’t wrong—EFM is flawed. It was specifically developed to reduce the risk of cerebral palsy, and it has definitively failed to do so. It has a high false-positive rate and is undeniably overused in low-risk, healthy pregnancies where intermittent auscultation would often suffice.
But as a Labor and Delivery nurse of 12 years and a Legal Nurse Consultant who analyzes these fetal heart rate strips for malpractice cases, I believe blaming the “machine” misses the most critical factor in the room: The competence of the human interpreting it.
The monitor is just a tool. It provides data. The crisis we are seeing isn’t solely because the tool is “bad”; it’s because the skill required to interpret that data is often lacking, inconsistent, or clouded by fear.
The “False Positive” vs. The “Human Factor”
The common argument, echoed in the article, is that the monitor cries wolf, leading to panic and unnecessary surgery. I see it differently. The monitor shows a change— a deceleration, a loss of variability. It is then up to the clinician (nurse, midwife, or physician) to answer the question: Is this a baby in trouble, or a baby who is merely sleeping or compressing their cord momentarily? What change in physiology does this pattern change reflect? Are there any reassuring characteristics in the pattern?
When we see C-section rates skyrocket, it often reflects a knowledge gap. It reflects a team that lacks the confidence to use intrauterine resuscitation measures—turning the mom, IV fluid boluses, stopping Pitocin—to fix the tracing. Instead, they see an indeterminate pattern, they panic, and they cut.
If the interpreter is competent, EFM is not an “electronic leash” of doom; it is a window into the fetal environment that allows us to intervene before a catastrophe happens.
The View from the Legal Files
In my work as a Legal Nurse Consultant, I review charts where bad outcomes occurred. Rarely is the issue that the machine “tricked” everyone. The liability usually lands in two distinct camps:
- Failure to Rescue: The team ignored clear signs of deterioration (worsening Categiry II or Category III tracings) and sat on their hands until it was too late.
- Failure to Interpret: The team misclassified a tracing, mistaking a benign pattern for a pathological one (leading to unnecessary surgery) or vice versa (leading to injury).
The “Standard of Care” demands not just that we use the monitor, but that we understand what it is saying. The legal system doesn’t punish hospitals for using EFM; it punishes them for using it poorly.
Standardizing the Language
The real protective factor—for both the mother’s uterus, the fetus’ well-being and the hospital’s legal standing—is rigorous adherence to NICHD terminology. We need nurses and doctors who are certified in EFM (C-EFM) and who speak the same language.
When a nurse can confidently look at a strip and say, “This is moderate variability with recurrent variable decelerations; I am going to change the maternal position and request orders for an amnioinfusion to relieve cord compression,” rather than just saying “The baby looks bad,” we save moms from surgery.
Why AI Can’t Replace the Bedside Nurse
With the rise of technology, there is a growing push to let Artificial Intelligence “read” these strips for us. While AI systems can be excellent at flagging variable decelerations or calculating contraction frequency, they fundamentally lack the one thing required for safe interpretation: clinical context.
An algorithm sees a drop in heart rate and flags it as a danger. It does not know that the mother just received an epidural bolus, or that she is vomiting, or that she just rolled onto her back. It cannot differentiate between a dying battery and a dying baby with the nuance of a human eye.
AI is a powerful “second opinion,” but it cannot replace a skilled professional who is well-versed in the nuanced physiology of labor and birth. Reliance on automation without human critical thinking is just another form of the same problem: trusting the data without understanding the patient.
The Verdict
Dr. Baron B. Caughey, one of the obstetricians who co-wrote the newly updated ACOG guidelines on fetal monitoring, summarizes it best: though the research is imperfect, clinical experience matters. We can admit that EFM is imperfect. We can admit it shouldn’t be the default for every low-risk mom who walks through the door. But we must also defend its efficacy when it is in the hands of an expert.
The solution isn’t just to unplug the machine. The solution is to elevate the education of the people watching it. When used correctly, by a clinician who understands fetal physiology and oxygenation, EFM doesn’t just cause c-sections—it improves outcomes and saves lives. The monitor is only as good as the provider watching it.
