What every expecting parent should know about electronic fetal monitoring

Electronic fetal monitoring (EFM) is a medical technology that allows doctors and nurses to monitor a fetus (unborn baby) during pregnancy, labor and delivery, identify fetal distress, and make a decision whether emergency delivery is necessary.

As a Houston, Texas medical malpractice attorney, I’ve handled many cases involving birth and brain injuries where electronic fetal monitoring evidence was critical. Invariably, defendant OB/GYN physicians, hospitals, and labor and delivery nurses hire medical expert to testify that EFM is unreliable and essentially useless.

Electronic fetal monitoring guidelines

Experienced birth injury attorneys know that this is smoke and mirrors designed to confuse juries. After all, I don’t think there’s a single hospital in America that doesn’t routinely use electronic fetal monitoring for every pregnant mother seen in the emergency room or labor and delivery department.

In 2007, in a rather transparent effort to protect OB/GYN physicians from liability for their medical errors, the American College of Obstetrics and Gynecology (ACOG) implemented new guidelines for how EFM interpretations should be classified and documented in patient medical records.

Before the new guidelines, OB/GYN doctors and labor and delivery nurses frequently used the terms “reassuring” and “nonreassuring” to describe their interpretation of electronic fetal monitoring strips. As the names suggest, reassuring EFM strip suggested no problems with the baby, and a nonreassuring strip, at a minimum, required physician notification, close monitoring, and additional testing.

The new EFM guidelines create three vague and ambiguous categories for documentation:

• Category I:  Indicates a low level of risk for  fetal hypoxia (lack of oxygen). Delivery of the baby is not required.

• Category II:  Anything that’s not Category I or Category III. The guidelines make no recommendation as to whether the baby should be delivered or not.

• Category III:  Indicates a high level of risk of fetal hypoxia, often when the fetal brain injury from a lack of oxygen has already occurred. Emergency delivery of the baby is required.

From a practical perspective, most EFM tracings are categorized as Category II. Unfortunately, there is a huge variety of differences in fetal risk for hypoxic brain injuries among the various electronic fetal monitoring strips that OB/GYNs and labor and delivery nurses described as Category II.

What’s required by the standard of care?

One of the questions in every medical malpractice lawsuit is what the doctor or nurse was supposed to do under the circumstances. Legally, we described that as the standard care—what a reasonable provider would have done under the same or similar circumstances.

When it comes to pregnancy, labor, and delivery, the standard care requires doctors to continuously assess the safety of the baby and mom, considering when safe delivery should occur. This includes closely watching the EFM readings to see if the baby is at risk for brain damage and may need emergency delivery.


Even when providers classify an EFM strip as Category II, it’s common for babies going into fetal distress to show a predictable pattern of deterioration that will show up on the electronic fetal monitoring, if the doctors and nurses are paying attention:

• Fetal heart rate decelerations (some decelerations, particularly late decelerations, are bad)

• An absence of fetal heart rate accelerations (accelerations are good)

• Significant decelerations that don’t quickly return to baseline

• Increase in the fetal heart rate baseline with frequent bursts or continuous tachycardia (rapid heart rate)

• Minimal baseline variability

• Deteriorating variability

• Absent variability during decelerations

• Prolonged bradycardia (abnormally low heart rate) which indicates compromised oxygen and blood flow.

If the OB/GYN and nursing staff are paying attention, they’ll often be able to catch early warning signs of hypoxia and ischemia (dangerously diminished oxygen and blood flow) on a fetal monitor strip. Unfortunately, it’s often the case that they become intellectually lazy and over-confident on an EFM pattern that they’ve described as Category II.

When there are signs of hypoxic compromise, the standard care requires an emergency delivery of the baby. It’s sad to see cases where the providers were seemingly on auto-pilot, missing clear signs of fetal distress, resulting in a baby born with a permanent brain injury that was avoidable.

Getting help

If your baby experienced a serious brain injury around the time of labor, delivery, and birth, it’s important to contact a top-rated medical malpractice lawyer with significant experience in handling this complex type of case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.