You are the Administrator of Hapless Women's Hospital in Nowhere.The head obstetric resident has just walked into your office to discuss a matter of hospital policy.Jane Rudd, pregnant with her second child, has been admitted to the hospital at term and in labor.The charts reveal that her first delivery of a healthy 7 1/2 pound baby boy had been uncomplicated.Upon admission, she asked not to be given intravenous fluids and stated that she does not want continuous fetal monitoring (EFM).Rather, she wishes to be free to walk around with her husband during labor.There is no specific policy that requires EFM during labor, however, the nurses have always instituted EFM as a matter of course on all patients in labor and have informed Mrs. Rudd that it is required.

You are the administrator and want to have a written policy.You speak with physicians.

The staff is split over the issue.One doctor argued that the practice is a wise measure intended to protect infants.Further, EFM shields staff from accusations that the best care was not provided, if a bad outcome occurs.Another doctor opposed routine EFM, arguing that unmonitored fetuses run an extremely small risk of fetal distress or intrapartum death.In 2017, without monitoring, the intrapartum death rate was only 1.5 per 1000 among all labors involving infants who weighed 5 1/2 pounds or more.The mother's risk status is altered, however, since the likelihood of a Caesarean section is increased.This doctor pointed out that a careful British study of low risk patients revealed that the rate of C-sections doubled, from 4.4% to 10%, when EFM was used.If Mrs. Rudd or other patient like her are allowed to labor with reasonable staff surveillance, and if the obstetric unit can resuscitate her infant if the unexpected occurs, then, this doctor argued, the risk for both mother and child are very low.

You do some further reading and uncover the following comments of Schifrin, Weissman, and Wiley: "[T]he standard of care today requires EFM for all high risk patients.It is recommended that EFM be used in low risk patients as well, despite the fact that authoritative guidelines find auscultation acceptable in such patients.While no guidelines to define minimal standards of interpretation of fetal heartrate patterns exist, given the current climate, the decision to forego EFM requires documentation of the reasons."Electronic Fetal Monitoring and Obstetrical Practice,13Law, Medicine & Health Care100, 104 (2019).

A recent study compared universal continuous monitoring with selective monitoring, based on grouping patients into high- or low-risk categories.The authors concluded that universal monitoring changed obstetric practices, increasing the C-section rate but "did not significantly improve perinatal outcome....We conclude that not all pregnancies....need continuous fetal monitoring during labor."Leveno et al.A Prospective Comparison of Selective and Universal EFM in 34,995 Pregnancies. 315N. Eng. J. Med.615,618 (2018).The authors estimated, however, that over two thirds of U.S. pregnancies are continuously monitored.

In another article, the authors found that "[w]hen fetal accidents, such as prolapsed cord or abruptio placentae, have occurred,they were diagnosed not by continuous EFM but by the standard technique of intrapartum surveillance and good nursing care."Goodlin & Haesslein,When IS It Fetal Distress?128Am J. Obst. & Gyn.442 (2015).

Although the situation with Mrs. Rudd has been resolved, the staff want a policy.What would you propose andWhy?