Excerpted from Birth as an American Rite of Passage

External Electronic Fetal Monitor

Description and Official Rationale

The pattern of the baby's heartbeat during labor often reflects the baby's condition. During contractions, the normal pattern is for the fetal heart rate to slow, picking up again as the contraction ends. The heart rate must be monitored during labor, because certain fluctuations in this pattern, such as precipitous drops in the heart rate at the end of a contraction, can constitute a true life or death situation requiring immediate emergency delivery of the baby. Before the invention of the electronic fetal monitor in the 1950s, nurses and doctors periodically monitored the baby's heartbeat themselves by placing a stethoscope on the mother's abdomen. Electronic monitors, attached to the mother by large belts strapped around her abdomen, continuously print out a record of both the fetal heartbeat and the strength, duration, and frequency of the uterine contractions, so that deviations from normal patterns can be identified. New attachments, not yet commonly used, may enable them also to monitor the mother's temperature, blood pressure, blood oxygen, heart rate, and cervical dilation (Arney 1982:146-148).

Physiological Effects

Part of what makes the use of the electronic fetal monitor so questionable is that acceptable degrees of variation in the fetal heart rate have never been firmly established. Not uncommonly, even extreme fluctuations result in perfectly normal babies born without technological intervention. Several studies have established that continuous external electronic monitoring is no more effective at identifying those fluctuations that do in fact indicate fetal distress than periodic manual auscultation (Chalmers 1978; Haverkamp and Orleans 1983).

The physician-inventor of the electronic fetal monitor, Dr. Edward H. Hon, identified several factors that could have an adverse effect on the fetal heart rate, and so made such monitoring seem most desirable: (1)intrinsic fetal disease; (2) placental disease; (3) cord compression; (4) maternal disease; (5) drugs administered for analgesia and anesthesia; and (6) maternal hypotension from the supine position, from conduction anesthesia, or from both (Hon 1974). Many of these factors are either directly generated by or made more dangerous in the hospital, where fetal infections commonly result from too many vaginal exams; where cord compression often results from improper maternal positioning and/or the administration of pitocin; and where drugs are often pressed on laboring women who otherwise might choose to do without (further examples of the "cranking gear" effect). At a conference on "Crisis in Obstetrics: The Management of Labor," held in New York City in March 1987, Hon himself emphatically stated, "If you mess around with a process that works well 98% of the time, there is much potential for harm....[most women in labor may be] much better off at home [than in the hospital with the electronic fetal monitor]" (Young and Shearer 1987).

According to Brackbill et al., in four methodologically sound studies carried out to evaluate the effects of electronic monitoring (Banta and Thacker 1979; Haverkamp and Orleans 1983), women in labor were randomly assigned to manually monitored and electronically monitored groups that were comparable in other respects:

Results were the same in all four studies: more electronically monitored women ended up...with Cesarean deliveries. Cesarean section rates ranged between 63% and 314% higher for electronically monitored women than manually monitored women. There was no improvement in perinatal outcome for the babies delivered by Cesarean section. The principal "reasons" alleged for these surgical deliveries--fetal distress and cephalopelvic disproportion (disproportion of head to pelvis)--cannot be proved or disproved. The real reasons, according to these studies, are attending physicians' impatience and nervousness. (Brackbill et al. 1984:10)

A subsequent and much larger study comparing the results of universal vs. selective monitoring of 34,995 parturients found no significant differences in stillbirths or fetal health between the universally monitored and selectively monitored groups; these researchers did find a slight but significant incidence in the incidence of Cesarean section for fetal distress in the universally monitored low-risk group (Leveno et al. 1986). Even in the high-risk case of prematurity, no benefits result from using electronic fetal monitors instead of periodic manual auscultation (Shy et al. 1990).

(For an excellent summation of all available studies on EFM published before 1987, see Prentice and Lind, "Fetal heart rate monitoring during labor-- too frequent intervention, too little benefit" [1987:2:1375-1377].) About the heightened risk of Cesarean resulting from EFM use, its inventor Dr. Hon had this to say, "Most obstetricians don't understand the monitor. They're dropping the knife with each drop in the fetal heart rate. The Cesarean section is considered as a rescue mission of the baby by the white knight, but actually you've assaulted the mother" (Young and Shearer 1987).

Besides the risk of unnecessary Cesarean section, other risks posed to the mother by the EFM include her immobilization in bed, which, as we have seen, can decrease her own blood supply and hence the oxygen supply to the fetus, leading to heart rate abnormalities, and "therefore, electronic monitoring tends to produce the very abnormalities it is supposed to measure" (Young and Shearer 1987:10-11). The authors of Williams Obstetrics (Pritchard, MacDonald, and Gant 1985; Cunningham, MacDonald, and Gant 1989), far from advocating universal monitoring, judiciously assess its limited benefits and considerable risks. At their hospital (Parkland Memorial in Dallas) in 1985, the monitors were used on about one-third of all laboring women under such circumstances as pitocin induction or augmentation, manually detected variations in fetal heart rate, and for conditions medically defined as high-risk, such as meconium staining, abnormal fetal presentation, maternal diabetes, or previous Cesarean delivery (Pritchard et al. 1985:291). By 1989, with the publication of the 18th edition of Williams, the number of women electronically monitored had risen to 40%. Somewhat caustically, the authors of both editions state:

Although the application of continuous electronic monitoring cannot by itself be credited for any remarkable reduction in intrapartum or neonatal mortality at Parkland Memorial hospital, it has provided an elegant means of demonstrating to physicians in training, medical students, nurses, physicians' assistants, and others the normal and abnormal forces of labor and the cardiac responses of the fetus during this important event. (Pritchard et al. 1985:290; Cunningham et al. 1989:302)

Supporters of electronic fetal monitors attribute the 1970s fall in the infant and perinatal death rate to their use. Critics point out that the decrease is attributable to other factors, such as a decrease in the number of unwanted pregancies, improved prenatal care and maternal nutrition, and increased intervals between births (Brackbill et al. 1984:10).

Women's Responses

As soon as I got hooked up to the monitor, all everyone did was stare at it. The nurses didn't even look at me any more when they came into the room--they went straight to the monitor. I got the weirdest feeling that it was having the baby, not me.
-Diana Crosse

[They put me in bed and] put on the fetal monitor. I didn't want fetal monitoring either. That was something else they agreed to. But they put it on "just to check"....That was kind of fun. I could watch [and my husband could help with the breathing better because he could tell when a contraction was starting sooner than I could, so he could help me get ready]....Then around seven ...I got real uncomfortable. I said "Get this thing off of me"--the fetal monitor--because I needed to rub--you know, do that Lamaze rub on my stomach. Well, if the fetal monitor is on, you can't rub. That's where I wanted to rub, so I said "Get it off of me." They said "Fine, we'll get it off.
-Patricia Hellman

Being hooked up to the monitor may seem a bit overly technological, but if it's going to make it easier for the doctor and the nurses, I'll do it.
-Alana Colson

In Diana's response to the electronic fetal monitor, we can observe the successful progression of conceptual fusion between Diana's perceptions of her birth experience and the technocratic model. So thoroughly has this model been "mapped on" to Diana's birth that she has begun to feel that the machine itself is having her baby, whereas she is reduced to a mere onlooker.

In contrast, in Pat's response to the fetal monitor, as well as in her demand for the enema and her earlier conversion of the wheelchair to a luggage cart, we can observe that by maintaining conceptual distance from the technocratic model, Pat is able to avoid conceptual fusion with the messages sent by obstetrical procedures. Conceptual distance can be maintained, as Pat demonstrates, when the woman places technology and the institution at her service, instead of the other way around.

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Ritual Purposes

A common feature of rites of passage across cultures is the ritual adornment of the initiates with the visible physical trappings of their transformation. In "primitive" (i.e., low technology) societies, these adornments usually consist of objects representing the most deeply held values and beliefs of the society, such as "relics of deities, heroes, or ancestors...sacred drums or other musical instruments" (Turner 1979:239). In Marine basic training, the rifle, backpack, and ammunition belt constitute the sacred symbols with which the initiate is adorned. This perspective provides a fascinating insight into the symbolic significance of the "EFM," a machine that has itself become the symbol of high technology hospital birth. Observers and participants alike report that the monitor, once attached, becomes the focal point of the labor, as nurses, physicians, husbands, and even laboring women themselves become visually and conceptually glued to the machine, which then shapes their perceptions and interpretations of the birth process--as in Diana's response above.

Under the technocratic model, the information produced by machines is considered more authoritative than the information produced by people. (Jordan and Irwin define "authoritative knowledge" as "legitimate, consequential, official, worthy of discussion, and useful for justifying actions by people engaged in accomplishing a certain task or objective" [1989:13]). Initially in medicine, the physician was totally dependent on the patient's verbal report and on his own senses of touch and observation for knowledge about an ailment or condition. With the invention of tests and procedures, medical practitioners have become increasingly removed from the need to physically interact with their patients. The recent shift in birth from a focus on the woman herself to a focus on diagnosis by machine parallels the same move in medicine as a whole (see Chapter 7), and both reflects and perpetuates our higher cultural valuation of objective knowledge over subjective experience. Brigitte Jordan (personal communication) reports repeated observations in hospitals of women still writhing in pain from an ongoing contraction while the nurse stood by insisting that, since the monitor was not recording it, the contraction must be over. Such indeed was the experience of several women in my study, one of whom added, "I even found myself apologizing to the nurse, who was waiting for the contraction to be over to do a cervical check, for the pain I was still feeling, because clearly I shouldn't have been feeling it." Such reliance on machines assures that the question of who knows what is really going on, as well as what is best for the woman and her baby, will be neatly resolved in favor of those who have access to the more valued technologically obtained information.

A further ritual and symbolic function provided by the electronic fetal monitor involves the role of rhythmic auditory stimuli in synchronizing the central nervous systems of ritual participants with the redundant symbolic messages presented in the ritual (as discussed in the Introduction): The amplified fetal heartbeat sounds like galloping horses, so with two or three monitors going in a room, the sound is one of a galloping herd. In the hall, the sounds of different monitors in different rooms fuse into a roar of childbirth. Frequently, there are also the intermittent commands to the women, "Push! Push!," reminiscent of stampedes and posse chases in the old Westerns. Both the sound of the galloping and the vision of the needle traveling across the paper, making a blip with each heartbeat, are hypnotic, often giving one the illusion that the machines are keeping the baby's heart beating. (Harrison 1982:90)

If we stop a moment now, to see in our mind's eye the visual and kinesthetic images that a laboring woman will be experiencing-- herself in bed, in a hospital gown, staring up at an IV pole, bag, and cord on one side, and a big whirring machine on the other, and down at a steel bed and a huge belt encircling her waist--we can see that her entire visual field is conveying one overwhelming perceptual message about our culture's deepest values and beliefs: technology is supreme, and you are utterly dependent upon it and the institutions that control and dispense it.

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