Continuous fetal monitoring
Because the fetal heart rate patterns seen when the heart rate is continuously recorded are sometimes difficult to interpret, EFM has increased the number of labors considered "complicated" or "risky." For women who do not have labor interventions such as epidurals that make continuous monitoring necessary, intermittent monitoring appears to be as effective as continuous monitoring at detecting true problems, and is not associated with an increased risk of Cesarean birth or of vaginal birth assisted by vacuum extraction or forceps.Changes in nursing care
In the past, personal one-on-one care was the hallmark of obstetrical nursing. Today, for a variety of reasons, including nursing shortages, budgetary constraints and less training in the natural progression of birth, labor nurses increasingly rely on continuous EFM to help them care for more than one woman at a time.Economic incentives
Many payment systems offer a single or fixed fee to doctors regardless of whether a baby is born vaginally or by Cesarean, and others offer a larger fee for a Cesarean. Doctors who patiently support natural labor, which starts at unpredictable hours and generally requires more time, are penalized financially. Inducing labor instead of waiting for it to start on its own also helps doctors control their hours. Elective Cesarean sections and scheduled induction of labor help hospitals make nursing staff schedules more predictable and shift more of health care providers' work to convenient weekday hours.Fear of lawsuits
If something goes wrong, doctors may be blamed for not doing something, but rarely are they blamed for doing something that is not necessary. For example, malpractice lawsuits for not performing a Cesarean section are much more common than lawsuits for doing one when it wasn't necessary. To avoid litigation, many doctors and some midwives feel compelled to do "too much" rather than be accused of doing "too little."A rushed, risk-averse society
U.S. society today has an aversion to risk that contributes to a climate of doubt in which all labors are treated as potential problems and women with low-risk pregnancies receive treatments designed for use by women with very high-risk ones. In addition, women sometimes are not allowed sufficient time for labor to progress and a vaginal birth to occur. Women's own expectations can contribute to rushing labor.
Often motivated by personal experiences, some of us have become involved in groups working to change birth practices (for one patient-turned-activist's story, see "Not in My State!"
). If you are healthy and have no medical complications that call for a "high-risk" approach to your care during pregnancy and birth, you can increase your chances of having a safe and satisfying vaginal birth by trying the following strategies:
• Find a doctor or midwife and a birth setting with low rates of intervention.
• Create your own birth plan and discuss it with your caregivers.
• Arrange for continuous labor support from someone with experience.
• Explore all your pain-relief options.
• Avoid continuous electronic fetal monitoring and other medically unnecessary interventions when possible.